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"prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2748298", "drug_name": "zidesamtinib 25 MG Oral Tablet [Jideytro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2748294", "drug_name": "zidesamtinib 100 MG Oral Tablet [Jideytro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2747783", "drug_name": "1.25 ML lecanemab-irmb 200 MG/ML Auto-Injector [Leqembi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2747520", "drug_name": "nilotinib 80 MG 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true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2746023", "drug_name": "{4 (milsaperidone 1 MG Oral Tablet [Bysanti]) / 2 (milsaperidone 2 MG Oral Tablet [Bysanti]) / 2 (milsaperidone 6 MG Oral Tablet [Bysanti]) } Pack [Bysanti Titration Pack C]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2746021", "drug_name": "{6 (milsaperidone 1 MG Oral Tablet [Bysanti]) / 2 (milsaperidone 2 MG Oral Tablet [Bysanti]) / 2 (milsaperidone 6 MG Oral Tablet [Bysanti]) / 2 (milsaperidone 8 MG Oral Tablet [Bysanti]) } Pack [Bysanti Titration Pack B]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2746019", "drug_name": "{2 (milsaperidone 1 MG Oral 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"duloxetine 90 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745865", "drug_name": "duloxetine 80 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745800", "drug_name": "milsaperidone 8 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745796", "drug_name": "milsaperidone 6 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745792", "drug_name": "milsaperidone 4 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745788", "drug_name": "milsaperidone 2 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745784", "drug_name": "milsaperidone 12 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745780", "drug_name": "milsaperidone 10 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745776", "drug_name": "milsaperidone 1 MG Oral Tablet [Bysanti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745415", "drug_name": "0.37 ML risankizumab-rzaa 149 MG/ML Prefilled Syringe [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745410", "drug_name": "deflazacort 22.75 MG/ML Oral Suspension [Kymbee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745133", "drug_name": "everolimus 7.5 MG Oral Tablet [Yulithira]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745131", "drug_name": "everolimus 5 MG Oral Tablet [Yulithira]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745129", "drug_name": "everolimus 2.5 MG Oral Tablet [Yulithira]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2745127", "drug_name": "everolimus 10 MG Oral Tablet [Yulithira]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2744515", "drug_name": "{21 (bupropion hydrochloride 105 MG / dextromethorphan hydrobromide 30 MG Extended Release Oral Tablet [Auvelity]) / 30 (bupropion hydrochloride 105 MG / dextromethorphan hydrobromide 45 MG Extended Release Oral Tablet [Auvelity]) } Pack [Auvelity Titration Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743365", "drug_name": "vepdegestrant 200 MG Oral Tablet [Veppanu]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743361", "drug_name": "vepdegestrant 100 MG Oral Tablet [Veppanu]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743044", "drug_name": "24 HR ruxolitinib 55 MG Extended Release Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743035", "drug_name": "24 HR ruxolitinib 44 MG Extended Release Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743028", "drug_name": "24 HR ruxolitinib 33 MG Extended Release Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743022", "drug_name": "24 HR ruxolitinib 22 MG Extended Release Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2743016", "drug_name": "24 HR ruxolitinib 11 MG Extended Release Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2741711", "drug_name": "120 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.018 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2741708", "drug_name": "28 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.018 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2741700", "drug_name": "doravirine 100 MG / islatravir 0.25 MG Oral Tablet [Idvynso]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2740803", "drug_name": "clonidine hydrochloride 0.05 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2740800", "drug_name": "0.5 ML ustekinumab-stba 90 MG/ML Injection [Steqeyma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739564", "drug_name": "{9 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 18 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 150 MG, 9-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739562", "drug_name": "{3 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 6 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 150 MG, 3-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739560", "drug_name": "{9 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 9 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 125 MG, 9-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739558", "drug_name": "{3 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 3 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 125 MG, 3-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739556", "drug_name": "{1 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 2 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 150 MG, 1-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739554", "drug_name": "{1 (relacorilant 100 MG Oral Capsule [Lifyorli]) / 1 (relacorilant 25 MG Oral Capsule [Lifyorli]) } Pack [Lifyorli 125 MG, 1-Dose Supply]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739504", "drug_name": "0.4 ML pegfilgrastim 10 MG/ML Injection [Neulasta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2739001", "drug_name": "gabapentin 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2737541", "drug_name": "doxecitine 2000 MG / doxribtimine 2000 MG Powder for Oral Solution [Kygevvi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2736948", "drug_name": "semaglutide 9 MG Oral Tablet [Ozempic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2736946", "drug_name": "semaglutide 4 MG Oral Tablet [Ozempic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2736944", "drug_name": "semaglutide 1.5 MG Oral Tablet [Ozempic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2732203", "drug_name": "{32 (24 HR gepirone 18.2 MG Extended Release Oral Tablet [Exxua]) } Pack [Exxua Titration Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2730169", "drug_name": "semaglutide 9 MG Oral Tablet [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2730167", "drug_name": "semaglutide 4 MG Oral Tablet [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2730165", "drug_name": "semaglutide 25 MG Oral Tablet [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2730161", "drug_name": "semaglutide 1.5 MG Oral Tablet [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2730156", "drug_name": "{4 (selinexor 80 MG Oral Tablet [Xpovio]) } Pack [Xpovio 80 MG Once Weekly Carton-80 MG Tablet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2729798", "drug_name": "cariprazine 0.75 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2729794", "drug_name": "cariprazine 0.5 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2728198", "drug_name": "sevabertinib 10 MG Oral Tablet [Hyrnuo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2727381", "drug_name": "deflazacort 22.75 MG/ML Oral Suspension [Jaythari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725996", "drug_name": "ziftomenib 200 MG Oral Capsule [Komzifti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725923", "drug_name": "imlunestrant 200 MG Oral Tablet [Inluriyo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725497", "drug_name": "deflazacort 36 MG Oral Tablet [Kymbee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725495", "drug_name": "deflazacort 30 MG Oral Tablet [Kymbee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725493", "drug_name": "deflazacort 18 MG Oral Tablet [Kymbee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725491", "drug_name": "deflazacort 6 MG Oral Tablet [Kymbee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725114", "drug_name": "26 ML ustekinumab-hmny 5 MG/ML Injection [Starjemza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725106", "drug_name": "0.5 ML ustekinumab-hmny 90 MG/ML Injection [Starjemza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725100", "drug_name": "1 ML ustekinumab-hmny 90 MG/ML Prefilled Syringe [Starjemza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2725094", "drug_name": "0.5 ML ustekinumab-hmny 90 MG/ML Prefilled Syringe [Starjemza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2724466", "drug_name": "lamotrigine 10 MG/ML Oral Suspension [Subvenite]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2724367", "drug_name": "{14 (24 HR apremilast 75 MG Extended Release Oral Tablet [Otezla]) / 4 (apremilast 10 MG Oral Tablet [Otezla]) / 4 (apremilast 20 MG Oral Tablet [Otezla]) / 19 (apremilast 30 MG Oral Tablet [Otezla]) } Pack [Otezla 28-Day 10/20/30/75 Starter Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723661", "drug_name": "selumetinib 7.5 MG Oral Granules [Koselugo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723657", "drug_name": "selumetinib 5 MG Oral Granules [Koselugo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723585", "drug_name": "liothyronine sodium 0.005 MG Oral Tablet [Liomny]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723583", "drug_name": "liothyronine sodium 0.05 MG Oral Tablet [Liomny]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723581", "drug_name": "liothyronine sodium 0.025 MG Oral Tablet [Liomny]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723452", "drug_name": "24 HR apremilast 75 MG Extended Release Oral Tablet [Otezla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2723411", "drug_name": "1.8 ML lecanemab-irmb 200 MG/ML Auto-Injector [Leqembi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2721615", "drug_name": "zongertinib 60 MG Oral Tablet [Hernexeos]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2721205", "drug_name": "dordaviprone 125 MG Oral Capsule [Modeyso]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2720357", "drug_name": "{6 (iloperidone 1 MG Oral Tablet [Fanapt]) / 2 (iloperidone 2 MG Oral Tablet [Fanapt]) / 2 (iloperidone 6 MG Oral Tablet [Fanapt]) / 2 (iloperidone 8 MG Oral Tablet [Fanapt]) } Pack [Fanapt Titration Pack B]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2720071", "drug_name": "finerenone 40 MG Oral Tablet [Kerendia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2719778", "drug_name": "0.5 ML varicella zoster virus glycoprotein E, recombinant 0.1 MG/ML Prefilled Syringe [Shingrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2719337", "drug_name": "tolvaptan 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2719335", "drug_name": "tolvaptan 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2719223", "drug_name": "zanubrutinib 160 MG Oral Tablet [Brukinsa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2719198", "drug_name": "deflazacort 22.75 MG/ML Oral Suspension [Pyquvi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2717873", "drug_name": "1.7 ML denosumab-bmwo 70 MG/ML Injection [Osenvelt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2717862", "drug_name": "1 ML denosumab-bmwo 60 MG/ML Prefilled Syringe [Stoboclo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716931", "drug_name": "taletrectinib 200 MG Oral Capsule [Ibtrozi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716710", "drug_name": "deflazacort 6 MG Oral Tablet [Jaythari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716708", "drug_name": "deflazacort 36 MG Oral Tablet [Jaythari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716706", "drug_name": "deflazacort 30 MG Oral Tablet [Jaythari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716704", "drug_name": "deflazacort 18 MG Oral Tablet [Jaythari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716697", "drug_name": "2 ML spesolimab-sbzo 150 MG/ML Prefilled Syringe [Spevigo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716571", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Meleya 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2716408", "drug_name": "28 ACTUAT teriparatide 0.02 MG/ACTUAT Pen Injector [Bonsity]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2715520", "drug_name": "1 ML denosumab-bbdz 60 MG/ML Prefilled Syringe [Jubbonti]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2715393", "drug_name": "1.7 ML denosumab-bbdz 70 MG/ML Injection [Wyost]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2714922", "drug_name": "{24 (avutometinib 0.8 MG Oral Capsule [Avmapki]) / 42 (defactinib 200 MG Oral Tablet [Fakzynja]) } Pack [Avmapki Fakzynja Co-Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2714657", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) } Pack [Luizza 1/20 21 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2714235", "drug_name": "{4 (iloperidone 1 MG Oral Tablet [Fanapt]) / 2 (iloperidone 2 MG Oral Tablet [Fanapt]) / 2 (iloperidone 6 MG Oral Tablet [Fanapt]) } Pack [Fanapt Titration Pack C]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712691", "drug_name": "sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712689", "drug_name": "sapropterin dihydrochloride 100 MG Powder for Oral Solution [Zelvysia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712644", "drug_name": "ensartinib 25 MG Oral Capsule [Ensacove]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712640", "drug_name": "ensartinib 100 MG Oral Capsule [Ensacove]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712092", "drug_name": "{21 (ethinyl estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) } Pack [Luizza 1.5/30 21 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2712088", "drug_name": "5 ML efgartigimod alfa-qvfc 200 MG/ML / hyaluronidase-qvfc 2000 UNT/ML Prefilled Syringe [Vyvgart Hytrulo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2711694", "drug_name": "isotretinoin 30 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2711638", "drug_name": "{2 (2 ML guselkumab 100 MG/ML Auto-Injector [Tremfya]) } Pack [Tremfya Induction Pack for Crohn's Disease]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2710426", "drug_name": "cobicistat 150 MG / darunavir 675 MG Oral Tablet [Prezcobix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2710422", "drug_name": "chenodeoxycholate 250 MG Oral Tablet [Ctexli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2708339", "drug_name": "{16 (selinexor 10 MG Oral Tablet [Xpovio]) } Pack [Xpovio 40 MG Once Weekly Carton-10 MG Tablet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2707132", "drug_name": "0.8 ML chikungunya virus antigen, recombinant Senegal strain 37997 0.05 MG/ML Prefilled Syringe [Vimkunya]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2706647", "drug_name": "{28 (estradiol 0.5 MG / norethindrone acetate 0.1 MG Oral Tablet) } Pack [Abigale Lo 0.5/0.1 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2706646", "drug_name": "{28 (estradiol 1 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack [Abigale 1/0.5 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705635", "drug_name": "mirdametinib 1 MG Tablet for Oral Suspension [Gomekli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705628", "drug_name": "mirdametinib 2 MG Oral Capsule [Gomekli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705623", "drug_name": "mirdametinib 1 MG Oral Capsule [Gomekli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705603", "drug_name": "0.5 ML ustekinumab-kfce 90 MG/ML Injection [Yesintek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705600", "drug_name": "1 ML ustekinumab-kfce 90 MG/ML Prefilled Syringe [Yesintek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705597", "drug_name": "0.5 ML ustekinumab-kfce 90 MG/ML Prefilled Syringe [Yesintek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705588", "drug_name": "26 ML ustekinumab-kfce 5 MG/ML Injection [Yesintek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705467", "drug_name": "0.5 ML Neisseria meningitidis serogroup A oligosaccharide diphtheria CRM197 protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup B recombinant FHBP fusion protein antigen 0.1 MG/ML / Neisseria meningitidis serogroup B recombinant NADA fusion protein antigen 0.1 MG/ML / Neisseria meningitidis serogroup B recombinant NHBA fusion protein antigen 0.1 MG/ML / Neisseria meningitidis serogroup B strain NZ98/254 outer membrane vesicle 0.05 MG/ML / Neisseria meningitidis serogroup C...", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705453", "drug_name": "4 ML tocilizumab-anoh 20 MG/ML Injection [Avtozma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705451", "drug_name": "20 ML tocilizumab-anoh 20 MG/ML Injection [Avtozma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705448", "drug_name": "10 ML tocilizumab-anoh 20 MG/ML Injection [Avtozma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705439", "drug_name": "0.9 ML tocilizumab-anoh 180 MG/ML Auto-Injector [Avtozma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705432", "drug_name": "0.9 ML tocilizumab-anoh 180 MG/ML Prefilled Syringe [Avtozma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705420", "drug_name": "vimseltinib 30 MG Oral Capsule [Romvimza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705416", "drug_name": "vimseltinib 20 MG Oral Capsule [Romvimza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2705412", "drug_name": "vimseltinib 14 MG Oral Capsule [Romvimza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704987", "drug_name": "{6 (nirmatrelvir 150 MG Oral Tablet) / 5 (ritonavir 100 MG Oral Tablet) } Pack [Paxlovid 300 MG /100 MG ; 150 MG / 100 MG Dose Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704839", "drug_name": "suzetrigine 50 MG Oral Tablet [Journavx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704562", "drug_name": "{21 (ethinyl estradiol 0.05 MG / ethynodiol diacetate 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Valtya 1/50 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704561", "drug_name": "{21 (ethinyl estradiol 0.035 MG / ethynodiol diacetate 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Valtya 1/35 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704560", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Orquidea 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2703270", "drug_name": "{21 (ethinyl estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) / 7 (ferrous fumarate 75 MG Oral Tablet) } Pack [Feirza 1.5/30 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2703269", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) / 7 (ferrous fumarate 75 MG Oral Tablet) } Pack [Feirza 1/20 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2702601", "drug_name": "abiraterone acetate 250 MG Oral Tablet [Abirtega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2701428", "drug_name": "0.8 ML olezarsen 100 MG/ML Auto-Injector [Tryngolza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2700412", "drug_name": "1 ML ustekinumab-stba 90 MG/ML Prefilled Syringe [Steqeyma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2700409", "drug_name": "0.5 ML ustekinumab-stba 90 MG/ML Prefilled Syringe [Steqeyma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2700400", "drug_name": "26 ML ustekinumab-stba 5 MG/ML Injection [Steqeyma]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2699837", "drug_name": "imatinib 80 MG/ML Oral Solution [Imkeldi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2699618", "drug_name": "trazodone hydrochloride 10 MG/ML Oral Solution [Raldesy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698574", "drug_name": "nilotinib 95 MG Oral Tablet [Danziten]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698570", "drug_name": "nilotinib 71 MG Oral Tablet [Danziten]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698345", "drug_name": "revumenib 25 MG Oral Tablet [Revuforj]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698341", "drug_name": "revumenib 160 MG Oral Tablet [Revuforj]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698337", "drug_name": "revumenib 110 MG Oral Tablet [Revuforj]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2698222", "drug_name": "Shortage Import Unapproved 1000 ML glucose 50 MG/ML / sodium chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2697170", "drug_name": "aripiprazole 10 MG Oral Film [Opipza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2697167", "drug_name": "aripiprazole 5 MG Oral Film [Opipza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2697164", "drug_name": "aripiprazole 2 MG Oral Film [Opipza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2696878", "drug_name": "repotrectinib 160 MG Oral Capsule [Augtyro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2696255", "drug_name": "norethindrone acetate 5 MG Oral Tablet [Gallifrey]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2695437", "drug_name": "inavolisib 9 MG Oral Tablet [Itovebi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2695433", "drug_name": "inavolisib 3 MG Oral Tablet [Itovebi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2694993", "drug_name": "{52 (trospium chloride 20 MG / xanomeline 100 MG Oral Capsule [Cobenfy]) / 4 (trospium chloride 20 MG / xanomeline 50 MG Oral Capsule [Cobenfy]) } Pack [Cobenfy 28-Day Starter Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2694991", "drug_name": "trospium chloride 20 MG / xanomeline 100 MG Oral Capsule [Cobenfy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2694855", "drug_name": "trospium chloride 30 MG / xanomeline 125 MG Oral Capsule [Cobenfy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2694850", "drug_name": "trospium chloride 20 MG / xanomeline 50 MG Oral Capsule [Cobenfy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693907", "drug_name": "2 ML lebrikizumab-lbkz 125 MG/ML Pen Injector [Ebglyss]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693791", "drug_name": "2 ML lebrikizumab-lbkz 125 MG/ML Prefilled Syringe [Ebglyss]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693253", "drug_name": "potassium chloride 15 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693193", "drug_name": "letermovir 120 MG Oral Pellet [Prevymis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693189", "drug_name": "letermovir 20 MG Oral Pellet [Prevymis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693097", "drug_name": "2 ML guselkumab 100 MG/ML Prefilled Syringe [Tremfya]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693095", "drug_name": "2 ML guselkumab 100 MG/ML Auto-Injector [Tremfya]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2693092", "drug_name": "20 ML guselkumab 10 MG/ML Injection [Tremfya]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2692052", "drug_name": "patiromer 1000 MG Powder for Oral Suspension [Veltassa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2691166", "drug_name": "lazertinib 240 MG Oral Tablet [Lazcluze]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2691162", "drug_name": "lazertinib 80 MG Oral Tablet [Lazcluze]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2690862", "drug_name": "{24 (tovorafenib 100 MG Oral Tablet [Ojemda]) } Pack [Ojemda 600 MG Once Weekly Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2690860", "drug_name": "{20 (tovorafenib 100 MG Oral Tablet [Ojemda]) } Pack [Ojemda 500 MG Once Weekly Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2690858", "drug_name": "{16 (tovorafenib 100 MG Oral Tablet [Ojemda]) } Pack [Ojemda 400 MG Once Weekly Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2690663", "drug_name": "vorasidenib 40 MG Oral Tablet [Voranigo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2690659", "drug_name": "vorasidenib 10 MG Oral Tablet [Voranigo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2688634", "drug_name": "vancomycin 2000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2688632", "drug_name": "vancomycin 1750 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2687207", "drug_name": "sotorasib 240 MG Oral Tablet [Lumakras]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2686613", "drug_name": "{7 (24 HR deutetrabenazine 12 MG Extended Release Oral Tablet [Austedo]) / 7 (24 HR deutetrabenazine 18 MG Extended Release Oral Tablet [Austedo]) / 7 (24 HR deutetrabenazine 24 MG Extended Release Oral Tablet [Austedo]) / 7 (24 HR deutetrabenazine 30 MG Extended Release Oral Tablet [Austedo]) } Pack [Austedo XR Once Daily, 4 Week Titration Pack, 12 MG / 18 MG / 24 MG / 30 MG]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2686156", "drug_name": "24 HR deutetrabenazine 18 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2686065", "drug_name": "2 ML tralokinumab-ldrm 150 MG/ML Auto-Injector [Adbry]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2686057", "drug_name": "0.9 ML tocilizumab-aazg 180 MG/ML Prefilled Syringe [Tyenne]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2686050", "drug_name": "0.9 ML tocilizumab-aazg 180 MG/ML Auto-Injector [Tyenne]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2685223", "drug_name": "vigabatrin 100 MG/ML Oral Solution [Vigafyde]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2685012", "drug_name": "0.5 ML respiratory syncytial virus pre-fusion F glycoprotein mRNA 0.1 MG/ML Prefilled Syringe [Mresvia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2684032", "drug_name": "mavorixafor 100 MG Oral Capsule [Xolremdi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683306", "drug_name": "100 ML furosemide 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683305", "drug_name": "50 ML furosemide 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683303", "drug_name": "24 HR deutetrabenazine 48 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683297", "drug_name": "24 HR deutetrabenazine 42 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683291", "drug_name": "24 HR deutetrabenazine 36 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2683285", "drug_name": "24 HR deutetrabenazine 30 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2682445", "drug_name": "tovorafenib 300 MG Powder for Oral Suspension [Ojemda]", "plans": [ { 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100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2680741", "drug_name": "naloxone hydrochloride 16 MG/ML Nasal Spray [Rextovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2680370", "drug_name": "{14 (nirogacestat 150 MG Oral Tablet [Ogsiveo]) } Pack [Ogsiveo 150 MG 7-Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2680364", "drug_name": "{14 (nirogacestat 100 MG Oral Tablet [Ogsiveo]) } Pack [Ogsiveo 100 MG 7-Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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Oral Tablet [Retevmo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679808", "drug_name": "selpercatinib 120 MG Oral Tablet [Retevmo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679502", "drug_name": "0.5 ML benralizumab 20 MG/ML Prefilled Syringe [Fasenra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2678984", "drug_name": "1 ML spesolimab-sbzo 150 MG/ML Prefilled Syringe [Spevigo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": 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infliximab-dyyb 120 MG/ML Prefilled Syringe [Zymfentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2675749", "drug_name": "1 ML infliximab-dyyb 120 MG/ML Pen Injector [Zymfentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2675318", "drug_name": "1 ML nedosiran 160 MG/ML Prefilled Syringe [Rivfloza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2675315", "drug_name": "0.8 ML nedosiran 160 MG/ML Prefilled Syringe [Rivfloza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2675309", "drug_name": "0.5 ML nedosiran 160 MG/ML Injection [Rivfloza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2673763", "drug_name": "0.5 ML omalizumab 150 MG/ML Auto-Injector [Xolair]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2673761", "drug_name": "1 ML omalizumab 150 MG/ML Auto-Injector [Xolair]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2673602", "drug_name": "0.6 ML pegfilgrastim-cbqv 10 MG/ML Injection [Udenyca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2673205", "drug_name": "eflornithine 192 MG Oral Tablet [Iwilfin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672397", "drug_name": "24 HR gepirone 72.6 MG Extended Release Oral Tablet [Exxua]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672391", "drug_name": "24 HR gepirone 54.5 MG Extended Release Oral Tablet [Exxua]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672385", "drug_name": "24 HR gepirone 36.3 MG Extended Release Oral Tablet [Exxua]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672379", "drug_name": "24 HR gepirone 18.2 MG Extended Release Oral Tablet [Exxua]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672328", "drug_name": "bosutinib 50 MG Oral Capsule [Bosulif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672326", "drug_name": "bosutinib 100 MG Oral Capsule [Bosulif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2671462", "drug_name": "methotrexate 2 MG/ML Oral Solution [Jylamvo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670655", "drug_name": "repotrectinib 40 MG Oral Capsule [Augtyro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670643", "drug_name": "nirogacestat 50 MG Oral Tablet [Ogsiveo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670629", "drug_name": "50 ML immunoglobulin G, human 200 MG/ML Prefilled Syringe [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670566", "drug_name": "0.5 ML Neisseria meningitidis serogroup A capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.01 MG/ML / Neisseria meningitidis serogroup B recombinant LP2086 A05 protein variant antigen 0.12 MG/ML / Neisseria meningitidis serogroup B recombinant LP2086 B01 protein variant antigen 0.12 MG/ML / Neisseria meningitidis serogroup C capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.01 MG/ML / Neisseria meningitidis serogroup W-135 capsular polysaccharide tetanus tox...", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670198", "drug_name": "fruquintinib 5 MG Oral Capsule [Fruzaqla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670190", "drug_name": "fruquintinib 1 MG Oral Capsule [Fruzaqla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670178", "drug_name": "crizotinib 50 MG Oral Pellet [Xalkori]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670174", "drug_name": "crizotinib 20 MG Oral Pellet [Xalkori]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2670170", "drug_name": "crizotinib 150 MG Oral Pellet [Xalkori]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669982", "drug_name": "capivasertib 200 MG Oral Tablet [Truqap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669978", "drug_name": "capivasertib 160 MG Oral Tablet [Truqap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669924", "drug_name": "zuranolone 30 MG Oral Capsule [Zurzuvae]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669920", "drug_name": "zuranolone 25 MG Oral Capsule [Zurzuvae]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669916", "drug_name": "zuranolone 20 MG Oral Capsule [Zurzuvae]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669472", "drug_name": "amylase 252600 UNT / lipase 60000 UNT / protease 189600 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2668599", "drug_name": "entrectinib 50 MG Oral Pellet [Rozlytrek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2668489", "drug_name": "{3 (0.8 ML adalimumab-aaty 100 MG/ML Auto-Injector) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2668487", "drug_name": "0.8 ML adalimumab-aaty 100 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2668483", "drug_name": "0.2 ML adalimumab-aaty 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2667423", "drug_name": "5 ML secukinumab 25 MG/ML Injection [Cosentyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2667342", "drug_name": "0.68 ML vedolizumab 159 MG/ML Auto-Injector [Entyvio]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2665912", "drug_name": "120 ACTUAT albuterol 0.09 MG/ACTUAT / budesonide 0.08 MG/ACTUAT Metered Dose Inhaler [Airsupra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2665216", "drug_name": "momelotinib 100 MG Oral Tablet [Ojjaara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2665163", "drug_name": "BX Rating tacrolimus 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2665162", "drug_name": "BX Rating tacrolimus 1 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2665161", "drug_name": "BX Rating tacrolimus 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2664894", "drug_name": "meropenem 2000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2663952", "drug_name": "2 ML pozelimab-bbfg 200 MG/ML Injection [Veopoz]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2663923", "drug_name": "2 ML omalizumab 150 MG/ML Auto-Injector [Xolair]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2663918", "drug_name": "2 ML omalizumab 150 MG/ML Prefilled Syringe [Xolair]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2645253", "drug_name": "abiraterone acetate 500 MG / niraparib 100 MG Oral Tablet [Akeega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2645250", "drug_name": "abiraterone acetate 500 MG / niraparib 50 MG Oral Tablet [Akeega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2644707", "drug_name": "21 DAY ethinyl estradiol 0.000625 MG/HR / etonogestrel 0.005 MG/HR Vaginal System [Enilloring]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2644512", "drug_name": "lotilaner 2.5 MG/ML Ophthalmic Solution [Xdemvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2643064", "drug_name": "quizartinib 26.5 MG Oral Tablet [Vanflyta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2643060", "drug_name": "quizartinib 17.7 MG Oral Tablet [Vanflyta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2642353", "drug_name": "vigabatrin 500 MG Oral Tablet [Vigadrone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2642350", "drug_name": "miglustat 100 MG Oral Capsule [Yargesa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2642214", "drug_name": "{4 (ozanimod 0.23 MG Oral Capsule [Zeposia]) / 3 (ozanimod 0.46 MG Oral Capsule [Zeposia]) / 21 (ozanimod 0.92 MG Oral Capsule [Zeposia]) } Pack [Zeposia 28-Day Starter Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2642148", "drug_name": "0.5 ML respiratory syncytial virus pre-fusion F protein, A, recombinant, stabilized 0.12 MG/ML / respiratory syncytial virus pre-fusion F protein, B, recombinant, stabilized 0.12 MG/ML Injection [Abrysvo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640895", "drug_name": "0.8 ML adalimumab-adbm 50 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640893", "drug_name": "0.4 ML adalimumab-adbm 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640891", "drug_name": "0.2 ML adalimumab-adbm 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640883", "drug_name": "0.8 ML adalimumab-adbm 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640417", "drug_name": "0.8 ML adalimumab-fkjp 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640412", "drug_name": "0.4 ML adalimumab-fkjp 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640404", "drug_name": "0.8 ML adalimumab-fkjp 50 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640214", "drug_name": "niraparib 300 MG Oral Tablet [Zejula]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640212", "drug_name": "niraparib 200 MG Oral Tablet [Zejula]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2640210", "drug_name": "niraparib 100 MG Oral Tablet [Zejula]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639966", "drug_name": "talazoparib 0.35 MG Oral Capsule [Talzenna]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639962", "drug_name": "talazoparib 0.1 MG Oral Capsule [Talzenna]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639957", "drug_name": "5.6 ML efgartigimod alfa-qvfc 180 MG/ML / hyaluronidase-qvfc 2000 UNT/ML Injection [Vyvgart Hytrulo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639750", "drug_name": "Pediatric 1.5 ML leuprolide acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639743", "drug_name": "Pediatric 1 ML leuprolide acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639727", "drug_name": "nalmefene 27 MG/ML Nasal Spray [Opvee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639659", "drug_name": "0.4 ML adalimumab-aaty 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2639651", "drug_name": "0.4 ML adalimumab-aaty 100 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2637767", "drug_name": "beremagene geperpavec-svdt 5000000000 UNT/ML Topical Suspension [Vyjuvek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2637556", "drug_name": "perfluorohexyloctane 1340 MG/ML Ophthalmic Solution [Miebo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2637476", "drug_name": "30 ACTUAT fluticasone furoate 0.05 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2637348", "drug_name": "2 ML secukinumab 150 MG/ML Auto-Injector [Cosentyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2637147", "drug_name": "fezolinetant 45 MG Oral Tablet [Veozah]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636793", "drug_name": "ivacaftor 5.8 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636789", "drug_name": "ivacaftor 13.4 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636599", "drug_name": "0.5 ML respiratory syncytial virus pre-fusion F protein, recombinant 0.24 MG/ML Injection [Arexvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636548", "drug_name": "fecal microbiota spores, live-brpk 30000000 UNT Oral Capsule [Vowst]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636052", "drug_name": "0.21 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636050", "drug_name": "0.14 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636048", "drug_name": "0.7 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636046", "drug_name": "0.56 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636044", "drug_name": "0.42 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636042", "drug_name": "0.35 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2636039", "drug_name": "0.28 ML risperidone 357 MG/ML Prefilled Syringe [Uzedy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2632564", "drug_name": "trametinib 0.05 MG/ML Oral Solution [Mekinist]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2632556", "drug_name": "dabrafenib 10 MG Tablet for Oral Suspension [Tafinlar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2632547", "drug_name": "0.6 ML pegfilgrastim-cbqv 10 MG/ML Auto-Injector [Udenyca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2632133", "drug_name": "100 ML daptomycin 7 MG/ML Injection", 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"rxnorm_id": "2631942", "drug_name": "omaveloxolone 50 MG Oral Capsule [Skyclarys]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630753", "drug_name": "cefazolin 3000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630671", "drug_name": "{126 (12 HR treprostinil 0.125 MG Extended Release Oral Tablet [Orenitram]) / 42 (12 HR treprostinil 0.25 MG Extended Release Oral Tablet [Orenitram]) / 84 (12 HR treprostinil 1 MG Extended Release Oral Tablet [Orenitram]) } Pack [Orenitram Month 3 Titration Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630669", "drug_name": "{126 (12 HR treprostinil 0.125 MG Extended Release Oral Tablet [Orenitram]) / 210 (12 HR treprostinil 0.25 MG Extended Release Oral Tablet [Orenitram]) } Pack [Orenitram Month 2 Titration Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630667", "drug_name": "{126 (12 HR treprostinil 0.125 MG Extended Release Oral Tablet [Orenitram]) / 42 (12 HR treprostinil 0.25 MG Extended Release Oral Tablet [Orenitram]) } Pack [Orenitram Month 1 Titration Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630550", "drug_name": "sparsentan 400 MG Oral Tablet [Filspari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630546", "drug_name": "sparsentan 200 MG Oral Tablet [Filspari]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630217", "drug_name": "apalutamide 240 MG Oral Tablet [Erleada]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630157", "drug_name": "24 HR deutetrabenazine 6 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630153", "drug_name": "24 HR deutetrabenazine 24 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2630147", "drug_name": "24 HR deutetrabenazine 12 MG Extended Release Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2629353", "drug_name": "pirtobrutinib 50 MG Oral Tablet [Jaypirca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2629349", "drug_name": "pirtobrutinib 100 MG Oral Tablet [Jaypirca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2628489", "drug_name": "elacestrant 345 MG Oral Tablet [Orserdu]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2628484", "drug_name": "elacestrant 86 MG Oral Tablet [Orserdu]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2628242", "drug_name": "sotorasib 320 MG Oral Tablet [Lumakras]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2628208", "drug_name": "{35 (futibatinib 4 MG 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[Rotarix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2626828", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Emzahh 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2626399", "drug_name": "pexidartinib 125 MG Oral Capsule [Turalio]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2626366", "drug_name": "citric acid 68.6 MG/ML / magnesium oxide 20 MG/ML / picosulfate sodium 0.0571 MG/ML Oral Solution [Clenpiq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2625923", "drug_name": "adagrasib 200 MG Oral Tablet [Krazati]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2625912", "drug_name": "{2 (1.5 ML lenacapavir 309 MG/ML Injection [Sunlenca]) } Pack [Sunlenca 927 MG Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2625900", "drug_name": "{5 (lenacapavir 300 MG Oral Tablet [Sunlenca]) } Pack [Sunlenca 5-Tablet Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2625898", "drug_name": "{4 (lenacapavir 300 MG Oral Tablet [Sunlenca]) } Pack [Sunlenca 4-Tablet Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2625896", "drug_name": "lenacapavir 300 MG Oral Tablet [Sunlenca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2623654", "drug_name": "olutasidenib 150 MG Oral Capsule [Rezlidhia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2623472", "drug_name": "isavuconazonium sulfate 74.5 MG Oral Capsule [Cresemba]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619912", "drug_name": "trientine hydrochloride 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619685", "drug_name": "1250 MG estradiol 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619683", "drug_name": "1000 MG estradiol 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619681", "drug_name": "750 MG estradiol 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619679", "drug_name": "500 MG estradiol 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619677", "drug_name": "250 MG estradiol 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2619154", "drug_name": "0.25 MG, 0.5 MG Dose 3 ML semaglutide 0.68 MG/ML Pen Injector [Ozempic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2613759", "drug_name": "1.2 ML risankizumab-rzaa 150 MG/ML Cartridge [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2611540", "drug_name": "ibrutinib 70 MG/ML Oral Suspension [Imbruvica]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2611266", "drug_name": "bupropion hydrochloride 105 MG / dextromethorphan hydrobromide 45 MG Extended Release Oral Tablet [Auvelity]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, 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"prior_authorization": false, "step_therapy": true, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2606490", "drug_name": "pirfenidone 534 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2604700", "drug_name": "ganaxolone 50 MG/ML Oral Suspension [Ztalmy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2604628", "drug_name": "2.4 ML risankizumab-rzaa 150 MG/ML Cartridge [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2604622", "drug_name": "10 ML risankizumab-rzaa 60 MG/ML Injection [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2603514", "drug_name": "0.5 ML measles virus vaccine live, attenuated Schwarz strain 5024 UNT/ML / mumps virus vaccine live, RIT-4385 strain 31684 UNT/ML / rubella virus vaccine live (Wistar RA 27-3 strain) 3990 UNT/ML Injection [Priorix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2601785", "drug_name": "0.5 ML tirzepatide 15 MG/ML Auto-Injector [Mounjaro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2601776", "drug_name": "0.5 ML tirzepatide 25 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] } ] }, { "rxnorm_id": "2594750", "drug_name": "{7 (mitapivat 20 MG Oral Tablet [Pyrukynd]) / 7 (mitapivat 50 MG Oral Tablet [Pyrukynd]) } Pack [Pyrukynd 20 MG / 50 MG Taper]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2594748", "drug_name": "{7 (mitapivat 20 MG Oral Tablet [Pyrukynd]) / 7 (mitapivat 5 MG Oral Tablet [Pyrukynd]) } Pack [Pyrukynd 5 MG / 20 MG Taper]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2594746", "drug_name": "{7 (mitapivat 5 MG Oral Tablet [Pyrukynd]) } Pack [Pyrukynd 5 MG Taper]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, 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"rxnorm_id": "2590643", "drug_name": "emtricitabine 120 MG / tenofovir alafenamide 15 MG Oral Tablet [Descovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2590054", "drug_name": "24 HR upadacitinib 30 MG Extended Release Oral Tablet [Rinvoq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2589384", "drug_name": "1 ML tralokinumab-ldrm 150 MG/ML Prefilled Syringe [Adbry]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2588062", "drug_name": "rivaroxaban 1 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", 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"2567237", "drug_name": "belzutifan 40 MG Oral Tablet [Welireg]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2564037", "drug_name": "belumosudil 200 MG Oral Tablet [Rezurock]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2564005", "drug_name": "odevixibat 1.2 MG Oral Capsule [Bylvay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2564001", "drug_name": "odevixibat 0.4 MG Oral Capsule [Bylvay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2563993", "drug_name": "odevixibat 0.6 MG Oral Pellet [Bylvay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2563989", "drug_name": "odevixibat 0.2 MG Oral Pellet [Bylvay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2562826", "drug_name": "finerenone 20 MG Oral Tablet [Kerendia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2562822", "drug_name": "finerenone 10 MG Oral Tablet [Kerendia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2559729", "drug_name": "avapritinib 50 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2559725", "drug_name": "avapritinib 25 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2559707", "drug_name": "1.14 ML dupilumab 175 MG/ML Auto-Injector [Dupixent]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2557910", "drug_name": "glecaprevir 50 MG / pibrentasvir 20 MG Oral Pellet [Mavyret]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2557391", "drug_name": "20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2557216", "drug_name": "{56 (elexacaftor 50 MG / ivacaftor 37.5 MG / tezacaftor 25 MG Oral Tablet) / 28 (ivacaftor 75 MG Oral Tablet) } Pack [Trikafta (50 MG / 37.5 MG / 25 MG; 75 MG)]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2554104", "drug_name": "0.75 ML semaglutide 3.2 MG/ML Auto-Injector [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2553903", "drug_name": "0.75 ML semaglutide 2.27 MG/ML Auto-Injector [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2553803", "drug_name": "0.5 ML semaglutide 2 MG/ML Auto-Injector [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2553603", "drug_name": "0.5 ML semaglutide 1 MG/ML Auto-Injector [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2553506", "drug_name": "0.5 ML semaglutide 0.5 MG/ML Auto-Injector [Wegovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2550725", "drug_name": "sotorasib 120 MG Oral Tablet [Lumakras]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2550713", "drug_name": "0.5 ML secukinumab 150 MG/ML Prefilled Syringe [Cosentyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2549333", "drug_name": "0.6 ML pegfilgrastim 10 MG/ML Injection [Neulasta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2548769", "drug_name": "{4 (selinexor 40 MG Oral Tablet [Xpovio]) } Pack [Xpovio 40 MG Once Weekly Carton-40 MG Tablet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2548767", "drug_name": "{8 (selinexor 40 MG Oral Tablet [Xpovio]) } Pack [Xpovio 40 MG Twice Weekly (80 MG total weekly dose- 40 MG Tablets) Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2548766", "drug_name": "{8 (selinexor 40 MG Oral Tablet [Xpovio]) } Pack [Xpovio 80 MG Once Weekly 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"AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2541237", "drug_name": "24 HR mirabegron 8 MG/ML Extended Release Suspension [Myrbetriq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2540709", "drug_name": "naloxone hydrochloride 80 MG/ML Nasal Spray [Kloxxado]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2540699", "drug_name": "1 ML risankizumab-rzaa 150 MG/ML Prefilled Syringe [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2540695", "drug_name": "1 ML risankizumab-rzaa 150 MG/ML Auto-Injector [Skyrizi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2540432", "drug_name": "{28 (cenobamate 100 MG Oral Tablet [Xcopri]) / 28 (cenobamate 150 MG Oral Tablet [Xcopri]) } Pack [Xcopri 250 MG Maintenance Pack - 100 MG (28), 150 MG (28) 56 Count]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2536742", "drug_name": "baloxavir marboxil 80 MG Oral Tablet [Xofluza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2534249", "drug_name": "tivozanib 1.34 MG Oral Capsule [Fotivda]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2534244", "drug_name": "tivozanib 0.89 MG Oral Capsule [Fotivda]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2531285", "drug_name": "168 HR ethinyl estradiol 0.00146 MG/HR / norelgestromin 0.00625 MG/HR Transdermal System [Zafemy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2478433", "drug_name": "tofacitinib 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2477272", "drug_name": "tepotinib 225 MG Oral Tablet [Tepmetko]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475860", "drug_name": "vericiguat 5 MG Oral Tablet [Verquvo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475856", "drug_name": "vericiguat 2.5 MG Oral Tablet [Verquvo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475852", "drug_name": "vericiguat 10 MG Oral Tablet [Verquvo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475418", "drug_name": "{1 (2 ML cabotegravir 200 MG/ML Injection) / 1 (2 ML rilpivirine 300 MG/ML Injection) } Pack [CABENUVA 400 MG / 600 MG]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475416", "drug_name": "{1 (3 ML cabotegravir 200 MG/ML Injection) / 1 (3 ML rilpivirine 300 MG/ML Injection) } Pack [CABENUVA 600 MG / 900 MG]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2475205", "drug_name": "cabotegravir 30 MG Oral Tablet [Vocabria]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2473042", "drug_name": "ponatinib 10 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2472789", "drug_name": "relugolix 120 MG Oral Tablet [Orgovyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2472321", "drug_name": "vibegron 75 MG Oral Tablet [Gemtesa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2472307", "drug_name": "{28 (ethinyl estradiol 0.02 MG / levonorgestrel 0.09 MG Oral Tablet) } Pack [Dolishale 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2468239", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.04 MG/ML / Bordetella pertussis fimbriae 2/3 vaccine, inactivated 0.01 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.006 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.04 MG/ML / diphtheria toxoid vaccine, inactivated 30 UNT/ML / Haemophilus influenzae b (Ross strain) capsular polysaccharide meningococcal protein conjugate vaccine 0.006 MG/ML / hepatitis B surface antigen vaccine 0.02 MG/M...", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2467592", "drug_name": "lonafarnib 75 MG Oral Capsule [Zokinvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2467588", "drug_name": "lonafarnib 50 MG Oral Capsule [Zokinvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2465556", "drug_name": "magnesium sulfate 225 MG / potassium chloride 188 MG / sodium sulfate 1479 MG Oral Tablet [Sutab]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2464832", "drug_name": "0.5 ML modified Vaccinia Ankara-Bavarian Nordic 198000000 UNT/ML Injection [Jynneos]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2463737", "drug_name": "epoetin alfa-epbx 20000 UNT/ML Injectable Solution [Retacrit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2463733", "drug_name": "epoetin alfa-epbx 10000 UNT/ML Injectable Solution [Retacrit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2399904", "drug_name": "84 HR estradiol 0.00417 MG/HR Transdermal System [Lyllana]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2399901", "drug_name": "84 HR estradiol 0.00313 MG/HR Transdermal System [Lyllana]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2399898", "drug_name": "84 HR estradiol 0.00208 MG/HR Transdermal System [Lyllana]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2399895", "drug_name": "84 HR estradiol 0.00156 MG/HR Transdermal System [Lyllana]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2399892", "drug_name": "84 HR estradiol 0.00104 MG/HR Transdermal System [Lyllana]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2398842", "drug_name": "3 ML semaglutide 1.34 MG/ML Pen Injector [Ozempic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2397128", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Lyleq 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2396774", "drug_name": "azacitidine 300 MG Oral Tablet [Onureg]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2396770", "drug_name": "azacitidine 200 MG Oral Tablet [Onureg]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2395785", "drug_name": "0.5 ML dulaglutide 9 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2395779", "drug_name": "0.5 ML dulaglutide 6 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2395775", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2395771", "drug_name": "14 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2394947", "drug_name": "pralsetinib 100 MG Oral Capsule [Gavreto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2392142", "drug_name": "0.5 ML etanercept 50 MG/ML Injection [Enbrel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2390954", "drug_name": "0.4 ML ofatumumab 50 MG/ML Pen Injector [Kesimpta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2390946", "drug_name": "risdiplam 0.75 MG/ML Oral Solution [Evrysdi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2390650", "drug_name": "enzalutamide 80 MG Oral Tablet [Xtandi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2390646", "drug_name": "enzalutamide 40 MG Oral Tablet [Xtandi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2387331", "drug_name": "120 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.009 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2387328", "drug_name": "28 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.009 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2384465", "drug_name": "{5 (cedazuridine 100 MG / decitabine 35 MG Oral Tablet [Inqovi]) } Pack [Inqovi 5 Tablet Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2383307", "drug_name": "10 ML hyaluronidase-zzxf 2000 UNT/ML / pertuzumab-zzxf 60 MG/ML / trastuzumab-zzxf 60 MG/ML Injection [Phesgo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2382990", "drug_name": "{24 (selinexor 20 MG Oral Tablet [Xpovio]) } Pack [Xpovio 60 MG Twice Weekly (120 MG total weekly dose) Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2382609", "drug_name": "15 ML hyaluronidase-zzxf 2000 UNT/ML / pertuzumab-zzxf 80 MG/ML / trastuzumab-zzxf 40 MG/ML Injection [Phesgo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2381144", "drug_name": "fenfluramine 2.2 MG/ML Oral Solution [Fintepla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2380551", "drug_name": "12 HR fostemsavir 600 MG Extended Release Oral Tablet [Rukobia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2380260", "drug_name": "3 ML insulin lispro-aabc 100 UNT/ML Pen Injector [Lyumjev]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2380256", "drug_name": "3 ML insulin lispro-aabc 200 UNT/ML Pen Injector [Lyumjev]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2380236", "drug_name": "insulin lispro-aabc 100 UNT/ML Injectable Solution [Lyumjev]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2375329", "drug_name": "2 ML dupilumab 150 MG/ML Auto-Injector [Dupixent]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2374566", "drug_name": "dolutegravir 5 MG Tablet for Oral Suspension [Tivicay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2373941", "drug_name": "bedaquiline 20 MG Oral Tablet [Sirturo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2369403", "drug_name": "ripretinib 50 MG Oral Tablet [Qinlock]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2362244", "drug_name": "capmatinib 200 MG Oral Tablet [Tabrecta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2362240", "drug_name": "capmatinib 150 MG Oral Tablet [Tabrecta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2361300", "drug_name": "tucatinib 50 MG Oral Tablet [Tukysa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2361296", "drug_name": "tucatinib 150 MG Oral Tablet [Tukysa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2360588", "drug_name": "0.5 ML Neisseria meningitidis serogroup A capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup C capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup W-135 capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup Y capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML Injection [Menquadfi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359358", "drug_name": "24 HR empagliflozin 5 MG / linagliptin 2.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359353", "drug_name": "24 HR empagliflozin 25 MG / linagliptin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359348", "drug_name": "pemigatinib 9 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359344", "drug_name": "pemigatinib 4.5 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359340", "drug_name": "pemigatinib 13.5 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359290", "drug_name": "24 HR empagliflozin 12.5 MG / linagliptin 2.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2359285", "drug_name": "24 HR empagliflozin 10 MG / linagliptin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2289428", "drug_name": "selumetinib 25 MG Oral Capsule [Koselugo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2289424", "drug_name": "selumetinib 10 MG Oral Capsule [Koselugo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2288433", "drug_name": "{4 (ozanimod 0.23 MG Oral Capsule [Zeposia]) / 3 (ozanimod 0.46 MG Oral Capsule [Zeposia]) } Pack [Zeposia 7-Day Starter Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2288412", "drug_name": "ozanimod 0.92 MG Oral Capsule [Zeposia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2287159", "drug_name": "20 ML immunoglobulin G, human 200 MG/ML Prefilled Syringe [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2286290", "drug_name": "osilodrostat 5 MG Oral Tablet [Isturisa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2286281", "drug_name": "osilodrostat 1 MG Oral Tablet [Isturisa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2284108", "drug_name": "palbociclib 75 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2284106", "drug_name": "palbociclib 125 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2284104", "drug_name": "palbociclib 100 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283540", "drug_name": "{14 (cenobamate 150 MG Oral Tablet [Xcopri]) / 14 (cenobamate 200 MG Oral 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283527", "drug_name": "cenobamate 25 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283518", "drug_name": "{28 (cenobamate 150 MG Oral Tablet [Xcopri]) / 28 (cenobamate 200 MG Oral Tablet) } Pack [Xcopri 350 MG Maintenance Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283513", "drug_name": "cenobamate 200 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283509", "drug_name": "cenobamate 150 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283505", "drug_name": "cenobamate 100 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2283236", "drug_name": "bempedoic acid 180 MG / ezetimibe 10 MG Oral Tablet [Nexlizet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2282414", "drug_name": "bempedoic acid 180 MG Oral Tablet [Nexletol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2282320", "drug_name": "rimegepant 75 MG Disintegrating Oral Tablet [Nurtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2275613", "drug_name": "lumateperone 42 MG Oral Capsule [Caplyta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2274390", "drug_name": "tazemetostat 200 MG Oral Tablet [Tazverik]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2273113", "drug_name": "24 HR tofacitinib 22 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272636", "drug_name": "{2 (0.1 ML) (diazepam 75 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 15 MG Dose Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272630", "drug_name": "{1 (0.1 ML) (diazepam 50 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 5 MG Dose Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272624", "drug_name": "{2 (0.1 ML) (diazepam 100 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 20 MG Dose Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272622", "drug_name": "{1 (0.1 ML) (diazepam 100 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 10 MG Dose Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272126", "drug_name": "avapritinib 300 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272122", "drug_name": "avapritinib 200 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2272118", "drug_name": "avapritinib 100 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2268231", "drug_name": "ubrogepant 50 MG Oral Tablet [Ubrelvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2268227", "drug_name": "ubrogepant 100 MG Oral Tablet [Ubrelvy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2268109", "drug_name": "10 ML immunoglobulin G, human 200 MG/ML Prefilled Syringe [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": 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"step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2123194", "drug_name": "Pulmonary Hypertension tadalafil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2123145", "drug_name": "erdafitinib 5 MG Oral Tablet [Balversa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2123141", "drug_name": "erdafitinib 4 MG Oral Tablet [Balversa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2123137", "drug_name": "erdafitinib 3 MG Oral Tablet [Balversa]", "plans": [ { 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"step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2122526", "drug_name": "dolutegravir 50 MG / lamivudine 300 MG Oral Tablet [Dovato]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2121100", "drug_name": "siponimod 2 MG Oral Tablet [Mayzent]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2121096", "drug_name": "siponimod 0.25 MG Oral Tablet [Mayzent]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2121061", "drug_name": "ceritinib 150 MG Oral Tablet [Zykadia]", "plans": [ { 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"FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1921081", "drug_name": "1.56 ML abaloparatide 2 MG/ML Pen Injector [Tymlos]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1919094", "drug_name": "midostaurin 25 MG Oral Capsule [Rydapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1918230", "drug_name": "valbenazine 40 MG Oral Capsule [Ingrezza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1918056", "drug_name": "{7 (ethinyl estradiol 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"drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1876916", "drug_name": "deutetrabenazine 12 MG Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1876810", "drug_name": "{21 (desogestrel 0.15 MG / ethinyl estradiol 0.02 MG Oral Tablet) / 5 (ethinyl estradiol 0.01 MG Oral Tablet) / 2 (inert ingredients 1 MG Oral Tablet) } Pack [Simliya 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1876502", "drug_name": "1 ML haloperidol 5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1876406", "drug_name": "2 ML dupilumab 150 MG/ML Prefilled Syringe [Dupixent]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1874559", "drug_name": "24 HR desvenlafaxine succinate 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1874553", "drug_name": "24 HR desvenlafaxine succinate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1873995", "drug_name": "{63 (ribociclib 200 MG Oral Tablet [Kisqali]) } Pack [Kisqali 600 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1873993", "drug_name": "{42 (ribociclib 200 MG Oral Tablet [Kisqali]) } Pack [Kisqali 400 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1873991", "drug_name": "{21 (ribociclib 200 MG Oral Tablet [Kisqali]) } Pack [Kisqali 200 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1872458", "drug_name": "telotristat ethyl 250 MG Oral Tablet [Xermelo]", 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"1870676", "drug_name": "2 ML gentamicin 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1870650", "drug_name": "2 ML gentamicin 40 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1870230", "drug_name": "NDA020800 0.3 ML epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1870225", "drug_name": "NDA020800 0.15 ML epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1870207", "drug_name": "NDA019430 0.3 ML epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1869699", "drug_name": "linaclotide 0.072 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1869684", "drug_name": "glutamine 5000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1868018", "drug_name": "pirfenidone 801 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1868014", "drug_name": "pirfenidone 267 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1867547", "drug_name": "potassium chloride 20 MEQ Powder for Oral Solution [Klor-Con]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1867544", "drug_name": "potassium chloride 20 MEQ Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1865962", "drug_name": "crisaborole 0.02 MG/MG Topical Ointment [Eucrisa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862701", "drug_name": "24 HR empagliflozin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862697", "drug_name": "24 HR empagliflozin 25 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862692", "drug_name": "24 HR empagliflozin 12.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862688", "drug_name": "24 HR empagliflozin 10 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862595", "drug_name": "rucaparib 200 MG Oral Tablet [Rubraca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862590", "drug_name": "rucaparib 300 MG Oral Tablet [Rubraca]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1860463", "drug_name": "100 ML potassium chloride 0.4 MEQ/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1860414", "drug_name": "{21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Afirmelle 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1860239", "drug_name": "100 ML potassium chloride 0.2 MEQ/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1859498", "drug_name": "eltrombopag 25 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1859000", "drug_name": "3 ML insulin glargine 100 UNT/ML / lixisenatide 0.033 MG/ML Pen Injector [Soliqua]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1858833", "drug_name": "12 HR treprostinil 5 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1857925", "drug_name": "maraviroc 20 MG/ML Oral Solution [Selzentry]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1856424", "drug_name": "{7 (ethinyl estradiol 0.035 MG / norethindrone 0.5 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 0.75 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Nylia 7/7/7 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1856402", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Nylia 1/35 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1855072", "drug_name": "24 HR calcifediol 0.03 MG Extended Release Oral Capsule [Rayaldee]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812951", "drug_name": "Vibrio cholerae CVD 103-HGR strain live antigen 12000000 UNT/ML Oral Suspension [Vaxchora]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812470", "drug_name": "ivacaftor 125 MG / lumacaftor 100 MG Oral Tablet [ORKAMBI]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812279", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Ayuna 28 Day Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812015", "drug_name": "Osmotic 24 HR nifedipine 90 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812013", "drug_name": "Osmotic 24 HR nifedipine 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1812011", "drug_name": "Osmotic 24 HR nifedipine 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1811180", "drug_name": "icosapent ethyl 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809525", "drug_name": "400 ML immunoglobulin G, human 100 MG/ML Injection [Privigen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809521", "drug_name": "50 ML immunoglobulin G, human 100 MG/ML Injection [Privigen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809520", "drug_name": "200 ML immunoglobulin G, human 100 MG/ML Injection [Privigen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809517", "drug_name": "100 ML immunoglobulin G, human 100 MG/ML Injection [Privigen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809422", "drug_name": "100 ML immunoglobulin G, human 100 MG/ML Injection [Bivigam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809416", "drug_name": "50 ML immunoglobulin G, human 100 MG/ML Injection [Bivigam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809077", "drug_name": "5 ML immunoglobulin G, human 200 MG/ML Injection [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809069", "drug_name": "10 ML immunoglobulin G, human 200 MG/ML Injection [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809067", "drug_name": "20 ML immunoglobulin G, human 200 MG/ML Injection [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809063", "drug_name": "50 ML immunoglobulin G, human 200 MG/ML Injection [Hizentra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809038", "drug_name": "10 ML immunoglobulin G, human 180 MG/ML Injection [GamaSTAN]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1809034", "drug_name": "2 ML immunoglobulin G, human 180 MG/ML Injection [GamaSTAN]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797888", "drug_name": "nicotine 0.5 MG/ACTUAT Metered Dose Nasal Spray [Nicotrol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797867", "drug_name": "azelastine hydrochloride 0.137 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797865", "drug_name": "mometasone furoate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797863", "drug_name": "flunisolide 0.025 MG/ACTUAT Metered 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"vortioxetine 5 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790890", "drug_name": "vortioxetine 20 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790886", "drug_name": "vortioxetine 10 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790684", "drug_name": "hydrocortisone 25 MG/ML Topical Cream [Procto-Med]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790533", "drug_name": "Abuse-Deterrent 12 HR oxycodone 9 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790175", "drug_name": "cabozantinib 60 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790171", "drug_name": "cabozantinib 40 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790167", "drug_name": "cabozantinib 20 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1790122", "drug_name": "perampanel 0.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1747697", "drug_name": "emtricitabine 200 MG / tenofovir alafenamide 25 MG Oral Tablet [Descovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1747580", "drug_name": "{14 (venetoclax 10 MG Oral Tablet [Venclexta]) / 21 (venetoclax 100 MG Oral Tablet [Venclexta]) / 7 (venetoclax 50 MG Oral Tablet [Venclexta]) } Pack [Venclexta Starting Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1747579", "drug_name": "venetoclax 50 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1747577", "drug_name": "venetoclax 10 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1747567", "drug_name": "venetoclax 100 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1745091", "drug_name": "lidocaine 0.05 MG/MG Medicated Patch", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1744009", "drug_name": "emtricitabine 167 MG / tenofovir disoproxil fumarate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1744005", "drug_name": "emtricitabine 133 MG / tenofovir disoproxil fumarate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1744001", "drug_name": "emtricitabine 100 MG / tenofovir disoproxil fumarate 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1741739", "drug_name": "emtricitabine 200 MG / rilpivirine 25 MG / tenofovir alafenamide 25 MG Oral Tablet [Odefsey]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1741046", "drug_name": "24 HR tofacitinib 11 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1739785", "drug_name": "brivaracetam 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1739780", "drug_name": "brivaracetam 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1739776", "drug_name": "brivaracetam 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1739772", "drug_name": "brivaracetam 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1739768", "drug_name": "brivaracetam 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"rxnorm_id": "1737244", "drug_name": "2 ML clindamycin 150 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736656", "drug_name": "ethinyl estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet [Fyavolv]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736654", "drug_name": "ethinyl estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736050", "drug_name": "levetiracetam 500 MG Tablet for Oral Suspension [Spritam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736048", "drug_name": "levetiracetam 500 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736047", "drug_name": "levetiracetam 250 MG Tablet for Oral Suspension [Spritam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736045", "drug_name": "levetiracetam 250 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1734934", "drug_name": "20 ML acyclovir 50 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1734932", "drug_name": "10 ML acyclovir 50 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1734683", "drug_name": "ertapenem 1000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1732014", "drug_name": "1 ML morphine sulfate 4 MG/ML Cartridge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1732006", "drug_name": "1 ML morphine sulfate 4 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1731995", "drug_name": "1 ML morphine sulfate 10 MG/ML Cartridge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1731993", "drug_name": "1 ML morphine sulfate 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1731317", "drug_name": "3 ML insulin, regular, human 500 UNT/ML Pen Injector [Humulin R]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1731020", "drug_name": "levetiracetam 500 MG Oral Tablet [Roweepra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1729516", "drug_name": "{21 (ethinyl estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) / 7 (ferrous fumarate 75 MG Oral Tablet) } Pack [Blisovi 21 Fe 1.5/30 28 Day Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1727569", "drug_name": "4 ML bumetanide 0.25 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1727485", "drug_name": "alectinib 150 MG Oral Capsule [Alecensa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1726639", "drug_name": "ponatinib 30 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1726214", "drug_name": "cilastatin 500 MG / imipenem 500 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1726204", "drug_name": "cilastatin 250 MG / imipenem 250 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724801", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) / 7 (ferrous fumarate 75 MG Oral Tablet) } Pack [Blisovi 21 Fe 1/20 28 Day Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724644", "drug_name": "1 ML hydromorphone hydrochloride 2 MG/ML Cartridge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724341", "drug_name": "50 ML hydromorphone hydrochloride 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724340", "drug_name": "5 ML hydromorphone hydrochloride 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724338", "drug_name": "1 ML hydromorphone hydrochloride 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1724276", "drug_name": "1 ML hydromorphone hydrochloride 2 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, 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"FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653579", "drug_name": "BCG, live, Tice strain 50 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653243", "drug_name": "1 ML secukinumab 150 MG/ML Auto-Injector [Cosentyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653225", "drug_name": "1 ML etanercept 50 MG/ML Auto-Injector [Enbrel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653217", "drug_name": "sapropterin dihydrochloride 500 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653204", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Pen Injector [NovoLog]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1653198", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Cartridge [NovoLog]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1652673", "drug_name": "doxycycline monohydrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1652646", "drug_name": "3 ML insulin lispro 100 UNT/ML Cartridge [Humalog]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1652640", "drug_name": "3 ML insulin lispro 100 UNT/ML Pen Injector [Humalog]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1652242", "drug_name": "3 ML insulin lispro 200 UNT/ML Pen Injector [Humalog]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1651275", "drug_name": "60 ACTUAT olodaterol 0.0025 MG/ACTUAT / tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Stiolto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1651271", "drug_name": "28 ACTUAT olodaterol 0.0025 MG/ACTUAT / tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Stiolto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650976", "drug_name": "2.63 ML paliperidone palmitate 311 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650974", "drug_name": "1.75 ML paliperidone palmitate 312 MG/ML Prefilled 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"prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650444", "drug_name": "doxycycline monohydrate 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650143", "drug_name": "doxycycline hyclate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650142", "drug_name": "doxycycline monohydrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650030", "drug_name": "doxycycline monohydrate 5 MG/ML Oral 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1649493", "drug_name": "ivabradine 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1649485", "drug_name": "ivabradine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1649429", "drug_name": "doxycycline monohydrate 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1649405", "drug_name": "doxycycline hyclate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1649401", "drug_name": "doxycycline monohydrate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648999", "drug_name": "triamcinolone acetonide 5 MG/ML Topical Cream [Triderm]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648789", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648788", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648785", "drug_name": "14 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648759", "drug_name": "nitrofurantoin, macrocrystals 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1648755", "drug_name": "nitrofurantoin, macrocrystals 25 MG / nitrofurantoin, monohydrate 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1608333", "drug_name": "isavuconazonium sulfate 186 MG Oral Capsule [Cresemba]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1608276", "drug_name": "cholic acid 50 MG Oral Capsule [Cholbam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1608274", "drug_name": "cholic acid 250 MG Oral Capsule [Cholbam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1607796", "drug_name": "deferasirox 90 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1607792", "drug_name": "deferasirox 360 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1607784", "drug_name": "deferasirox 180 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1607617", "drug_name": "24 HR desvenlafaxine succinate 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606870", "drug_name": "ivacaftor 75 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606866", "drug_name": "ivacaftor 50 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606349", "drug_name": "metoprolol tartrate 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606347", "drug_name": "metoprolol tartrate 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606337", "drug_name": "asenapine 2.5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1605455", "drug_name": "{4 (apremilast 10 MG Oral Tablet [Otezla]) / 4 (apremilast 20 MG Oral Tablet [Otezla]) / 47 (apremilast 30 MG Oral Tablet [Otezla]) } Pack [Otezla 28-Day 10/20/30 Starter Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1605257", "drug_name": "levonorgestrel 0.000813 MG/HR Intrauterine System [Liletta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1605088", "drug_name": "isotretinoin 30 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1605075", "drug_name": "0.8 ML filgrastim-sndz 0.6 MG/ML Prefilled Syringe [Zarxio]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1605071", "drug_name": "0.5 ML filgrastim-sndz 0.6 MG/ML Prefilled Syringe [Zarxio]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1604544", "drug_name": "1.5 ML insulin glargine 300 UNT/ML Pen Injector [Toujeo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1604395", "drug_name": "{60 (lenvatinib 10 MG Oral Capsule [Lenvima]) } Pack [Lenvima 20]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1604384", "drug_name": "{30 (lenvatinib 10 MG Oral Capsule [Lenvima]) } Pack [Lenvima 10]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1604352", "drug_name": "{60 (lenvatinib 10 MG Oral Capsule [Lenvima]) / 30 (lenvatinib 4 MG Oral Capsule [Lenvima]) } Pack [Lenvima 24]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1604350", "drug_name": "{30 (lenvatinib 10 MG Oral Capsule [Lenvima]) / 30 (lenvatinib 4 MG Oral Capsule [Lenvima]) } Pack [Lenvima 14]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1603861", "drug_name": "{7 (ethinyl estradiol 0.01 MG Oral Tablet) / 84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) } Pack [Ashlyna 91 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1602607", "drug_name": "2 ML aripiprazole 200 MG/ML Prefilled Syringe [Abilify]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1602604", "drug_name": "1.5 ML aripiprazole 200 MG/ML Prefilled Syringe [Abilify]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1602120", "drug_name": "empagliflozin 25 MG / linagliptin 5 MG Oral Tablet [Glyxambi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1602115", "drug_name": "empagliflozin 10 MG / linagliptin 5 MG Oral Tablet [Glyxambi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601982", "drug_name": "alanine 21.7 MG/ML / arginine 14.7 MG/ML / aspartate 4.34 MG/ML / glutamate 7.49 MG/ML / glycine 10.4 MG/ML / histidine 8.94 MG/ML / isoleucine 7.49 MG/ML / leucine 10.4 MG/ML / lysine 11.8 MG/ML / methionine 7.49 MG/ML / phenylalanine 10.4 MG/ML / proline 8.94 MG/ML / serine 5.92 MG/ML / threonine 7.49 MG/ML / tryptophan 2.5 MG/ML / tyrosine 0.39 MG/ML / valine 9.6 MG/ML Injectable Solution [Plenamine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601660", "drug_name": "atazanavir 300 MG / cobicistat 150 MG Oral Tablet [Evotaz]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601407", "drug_name": "0.5 ML meningococcal group B vaccine 0.1 MG/ML / Neisseria meningitidis serogroup B recombinant FHBP fusion protein antigen 0.1 MG/ML / Neisseria meningitidis serogroup B recombinant NHBA fusion protein antigen 0.1 MG/ML / Neisseria meningitidis serogroup B strain NZ98/254 outer membrane vesicle 0.05 MG/ML Prefilled Syringe [Bexsero]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601394", "drug_name": "palbociclib 75 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601390", "drug_name": "palbociclib 125 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601386", "drug_name": "palbociclib 100 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1601373", "drug_name": "naloxegol 25 MG Oral Tablet [Movantik]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600710", "drug_name": "cobicistat 150 MG / darunavir 800 MG Oral Tablet [Prezcobix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1599797", "drug_name": "1 ML secukinumab 150 MG/ML Prefilled Syringe [Cosentyx]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1598989", "drug_name": "atazanavir 50 MG Oral Powder [Reyataz]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597129", "drug_name": "5000 MG testosterone 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597126", "drug_name": "2500 MG testosterone 0.0162 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597123", "drug_name": "2500 MG testosterone 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597120", "drug_name": "1250 MG testosterone 0.0162 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597103", "drug_name": "0.5 ML L1 protein, human papillomavirus type 11 vaccine 0.08 MG/ML / L1 protein, human papillomavirus type 16 vaccine 0.12 MG/ML / L1 protein, human papillomavirus type 18 vaccine 0.08 MG/ML / L1 protein, human papillomavirus type 31 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 33 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 45 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 52 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 58 vaccine 0.04 MG...", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597099", "drug_name": "0.5 ML L1 protein, human papillomavirus type 11 vaccine 0.08 MG/ML / L1 protein, human papillomavirus type 16 vaccine 0.12 MG/ML / L1 protein, human papillomavirus type 18 vaccine 0.08 MG/ML / L1 protein, human papillomavirus type 31 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 33 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 45 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 52 vaccine 0.04 MG/ML / L1 protein, human papillomavirus type 58 vaccine 0.04 MG...", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1597076", "drug_name": "60 ACTUAT testosterone 20.25 MG/ACTUAT Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1596780", "drug_name": "60 ACTUAT testosterone 12.5 MG/ACTUAT Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1596445", "drug_name": "7 ACTUAT umeclidinium 0.0625 MG/ACTUAT Dry Powder Inhaler [Incruse]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": 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false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1593835", "drug_name": "24 HR dapagliflozin 10 MG / metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1593833", "drug_name": "24 HR dapagliflozin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1593831", "drug_name": "24 HR dapagliflozin 5 MG / metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1547114", "drug_name": "suvorexant 15 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1547110", "drug_name": "suvorexant 10 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1546894", "drug_name": "abacavir 600 MG / dolutegravir 50 MG / lamivudine 300 MG Oral Tablet [Triumeq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1545668", "drug_name": "empagliflozin 25 MG Oral Tablet [Jardiance]", "plans": [ { 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"rxnorm_id": "1543069", "drug_name": "lidocaine 0.05 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1542997", "drug_name": "168 HR buprenorphine 0.0075 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1541890", "drug_name": "sunitinib 37.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1540890", "drug_name": "tedizolid phosphate 200 MG Injection [Sivextro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"1539953", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Deblitane 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1539893", "drug_name": "30 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1539891", "drug_name": "14 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1539885", "drug_name": "30 ACTUAT umeclidinium 0.0625 MG/ACTUAT Dry Powder Inhaler [Incruse]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1539762", "drug_name": "efinaconazole 100 MG/ML Topical Solution [Jublia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1538130", "drug_name": "{21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Delyla 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1537209", "drug_name": "{21 (ethinyl estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral 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"drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1536144", "drug_name": "120 ACTUAT mometasone furoate 0.1 MG/ACTUAT Metered Dose Inhaler [Asmanex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1534809", "drug_name": "168 HR ethinyl estradiol 0.00146 MG/HR / norelgestromin 0.00625 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1495092", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Norlyroc 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1495070", "drug_name": "miltefosine 50 MG Oral Capsule [Impavido]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1492746", "drug_name": "apremilast 30 MG Oral Tablet [Otezla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1492742", "drug_name": "apremilast 20 MG Oral Tablet [Otezla]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490065", "drug_name": "raloxifene hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490038", "drug_name": "droxidopa 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490034", "drug_name": "droxidopa 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490026", "drug_name": "droxidopa 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1488679", "drug_name": "12 HR treprostinil 2.5 MG Extended Release 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"FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1488574", "drug_name": "dapagliflozin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1488569", "drug_name": "dapagliflozin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1487528", "drug_name": "30 ACTUAT umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Anoro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1487524", "drug_name": "7 ACTUAT umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Anoro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1487361", "drug_name": "1 ML glatiramer acetate 40 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1487288", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 2.5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1487086", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) } Pack [Larin 1/20]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1486981", "drug_name": "dapagliflozin 5 MG Oral Tablet [Farxiga]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1486977", "drug_name": "dapagliflozin 10 MG Oral Tablet [Farxiga]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1486841", "drug_name": "raltegravir 100 MG Granules for Oral Suspension [Isentress]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1486687", "drug_name": "sapropterin dihydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1486496", "drug_name": "0.5 ML typhoid Vi polysaccharide vaccine, S typhi Ty2 strain 0.05 MG/ML Prefilled Syringe [Typhim VI]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1485332", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 0.4 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Vyfemla 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1484296", "drug_name": "sucroferric oxyhydroxide 500 MG Chewable Tablet [Velphoro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1483744", "drug_name": "naltrexone hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482908", "drug_name": "posaconazole 100 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482525", "drug_name": "eslicarbazepine acetate 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482521", "drug_name": "eslicarbazepine acetate 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482515", "drug_name": "eslicarbazepine acetate 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482507", "drug_name": "eslicarbazepine acetate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1442992", "drug_name": "ibrutinib 140 MG Oral Capsule [Imbruvica]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1442137", "drug_name": "macitentan 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1440937", "drug_name": "{21 (ethinyl estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) / 7 (ferrous fumarate 75 MG Oral Tablet) } Pack [Larin Fe 1.5/30]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1440185", "drug_name": "{21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert 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"plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1439899", "drug_name": "riociguat 1.5 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1439896", "drug_name": "riociguat 1 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1439894", "drug_name": "riociguat 0.5 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1438778", "drug_name": "{21 (desogestrel 0.15 MG / ethinyl estradiol 0.02 MG Oral Tablet) / 5 (ethinyl estradiol 0.01 MG Oral Tablet) / 2 (inert ingredients 1 MG Oral Tablet) } Pack [Pimtrea Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1437969", "drug_name": "cyclophosphamide 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1437968", "drug_name": "cyclophosphamide 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1437713", "drug_name": "mechlorethamine 0.00016 MG/MG Topical Gel [Valchlor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1437702", "drug_name": "albuterol 0.833 MG/ML / ipratropium bromide 0.167 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1435115", "drug_name": "28 ACTUAT teriparatide 0.02 MG/ACTUAT Pen Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433879", "drug_name": "dolutegravir 50 MG Oral Tablet [Tivicay]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433250", "drug_name": "{2 (24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]) / 26 (24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]) } Pack [Fetzima Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433241", "drug_name": "24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433235", "drug_name": "24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433229", "drug_name": "24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1433223", "drug_name": "24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1432969", "drug_name": "168 HR buprenorphine 0.015 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1431985", "drug_name": "24 HR tacrolimus 5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1431980", "drug_name": "24 HR tacrolimus 1 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1431971", "drug_name": "24 HR tacrolimus 0.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1431235", "drug_name": "lurasidone hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1430457", "drug_name": "afatinib 40 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1430453", "drug_name": "afatinib 30 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1430449", "drug_name": "afatinib 20 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1430383", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Lyza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1428947", "drug_name": "lenalidomide 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1425230", "drug_name": "dabrafenib 75 MG Oral Capsule [Tafinlar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1425228", "drug_name": "dabrafenib 50 MG Oral Capsule [Tafinlar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1425118", "drug_name": "trametinib 2 MG Oral Tablet [Mekinist]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1425110", "drug_name": "trametinib 0.5 MG Oral Tablet [Mekinist]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1424889", "drug_name": "30 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1423123", "drug_name": "{7 (ethinyl estradiol 0.01 MG Oral Tablet) / 84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) } Pack [Daysee 91 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1422896", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Jencycla 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1421456", "drug_name": "brimonidine tartrate 2 MG/ML / brinzolamide 10 MG/ML Ophthalmic Suspension [Simbrinza]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1376336", "drug_name": "prednisolone acetate 10 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1375917", "drug_name": "bromfenac 0.7 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1374574", "drug_name": "{224 (tobramycin 28 MG Inhalation Powder [Tobi]) } Pack [TOBI Podhaler Kit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373497", "drug_name": "{14 (dimethyl fumarate 120 MG Delayed Release Oral Capsule) / 46 (dimethyl fumarate 240 MG Delayed Release Oral Capsule) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373491", "drug_name": "dimethyl fumarate 240 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373483", "drug_name": "dimethyl fumarate 120 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373337", "drug_name": "isotretinoin 40 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373335", "drug_name": "isotretinoin 20 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373333", "drug_name": "isotretinoin 10 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1373327", "drug_name": "amylase 180000 UNT / lipase 36000 UNT / protease 114000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1370982", "drug_name": "ospemifene 60 MG Oral Tablet [Osphena]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1370754", "drug_name": "hydrocortisone valerate 2 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369831", "drug_name": "clozapine 50 MG/ML Oral Suspension [Versacloz]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369770", "drug_name": "{7 (ethinyl estradiol 0.035 MG / norgestimate 0.18 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norgestimate 0.215 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norgestimate 0.25 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Tri-Estarylla 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369737", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norgestimate 0.25 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Estarylla 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369736", "drug_name": "pomalidomide 4 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369734", "drug_name": "pomalidomide 4 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369732", "drug_name": "pomalidomide 3 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369730", "drug_name": "pomalidomide 3 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369728", "drug_name": "pomalidomide 2 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369726", "drug_name": "pomalidomide 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369724", "drug_name": "pomalidomide 1 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369718", "drug_name": "pomalidomide 1 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1367436", "drug_name": "21 DAY ethinyl estradiol 0.000625 MG/HR / etonogestrel 0.005 MG/HR Vaginal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1366550", "drug_name": "24 HR budesonide 9 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1366192", "drug_name": "clobazam 2.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1365899", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norgestimate 0.25 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Mono-Linyah 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1365866", "drug_name": "nepafenac 3 MG/ML Ophthalmic Suspension [Ilevro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364848", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Chateal 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364581", "drug_name": "{84 (cabozantinib 20 MG Oral Capsule [Cometriq]) } Pack [Cometriq 60 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364515", "drug_name": "bedaquiline 100 MG Oral Tablet [Sirturo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364447", "drug_name": "apixaban 5 MG Oral Tablet [Eliquis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364441", "drug_name": "apixaban 2.5 MG Oral Tablet [Eliquis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364362", "drug_name": "ponatinib 45 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364358", "drug_name": "ponatinib 15 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364122", "drug_name": "1 ML pasireotide 0.9 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364118", "drug_name": "1 ML pasireotide 0.6 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364114", "drug_name": "1 ML pasireotide 0.3 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363410", "drug_name": "{28 (cabozantinib 20 MG Oral Capsule [Cometriq]) / 28 (cabozantinib 80 MG Oral Capsule [Cometriq]) } Pack [Cometriq 100 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363408", "drug_name": "{84 (cabozantinib 20 MG Oral Capsule [Cometriq]) / 28 (cabozantinib 80 MG Oral Capsule [Cometriq]) } Pack [Cometriq 140 MG Daily Dose Carton]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1362720", "drug_name": "mexiletine hydrochloride 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1362712", "drug_name": "mexiletine hydrochloride 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1362706", "drug_name": "mexiletine hydrochloride 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1361615", "drug_name": "heparin sodium, porcine 5000 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359269", "drug_name": "darunavir 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359129", "drug_name": "{28 (estradiol 1 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack [Mimvey]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359127", "drug_name": "{28 (estradiol 1 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359124", "drug_name": "{28 (estradiol 0.5 MG / norethindrone acetate 0.1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359032", "drug_name": "{21 (ethinyl 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false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359020", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) } Pack [Microgestin 1/20 21 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1358780", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) } Pack [Junel 1/20 21 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1358776", "drug_name": "{21 (ethinyl estradiol 0.02 MG / norethindrone acetate 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, 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0.00156 MG/HR Transdermal System [Minivelle]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356586", "drug_name": "perampanel 12 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356582", "drug_name": "perampanel 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356578", "drug_name": "perampanel 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356574", "drug_name": "perampanel 6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356570", "drug_name": "perampanel 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356557", "drug_name": "perampanel 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1356074", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Kurvelo]", "plans": [ { "plan_id_type": "PLAN-ID", 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} ] }, { "rxnorm_id": "1308569", "drug_name": "24 HR rivastigmine 0.554 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1308432", "drug_name": "everolimus 5 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1308430", "drug_name": "everolimus 3 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1308428", "drug_name": "everolimus 2 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307635", "drug_name": "bosutinib 500 MG Oral Tablet [Bosulif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307633", "drug_name": "bosutinib 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307630", "drug_name": "bosutinib 100 MG Oral Tablet [Bosulif]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307624", "drug_name": "bosutinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307421", "drug_name": "linaclotide 0.29 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307415", "drug_name": "linaclotide 0.145 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307309", "drug_name": "enzalutamide 40 MG Oral Capsule [Xtandi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307061", "drug_name": "buprenorphine 12 MG / naloxone 3 MG Sublingual Film", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1307056", "drug_name": "buprenorphine 4 MG / naloxone 1 MG Sublingual Film", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1306298", "drug_name": "cobicistat 150 MG / elvitegravir 150 MG / emtricitabine 200 MG / tenofovir disoproxil fumarate 300 MG Oral Tablet [Stribild]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1305089", "drug_name": "{21 (ethinyl estradiol 0.03 MG / 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"drug_name": "24 HR mirabegron 25 MG Extended Release Oral Tablet [Myrbetriq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300783", "drug_name": "0.5 ML Japanese encephalitis virus vaccine Nakayama-NIH strain, inactivated 0.012 MG/ML Prefilled Syringe [Ixiaro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300538", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Dasetta 1/35 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300468", "drug_name": "0.5 ML Haemophilus influenzae type b strain 1482, capsular polysaccharide inactivated tetanus toxoid conjugate vaccine 0.068 MG/ML Injection [ActHIB]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300384", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.05 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.016 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.05 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [Infanrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300370", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.016 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.005 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.016 MG/ML / diphtheria toxoid vaccine, inactivated 5 UNT/ML / tetanus toxoid vaccine, inactivated 10 UNT/ML Prefilled Syringe [Boostrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300310", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.01 MG/ML / Bordetella pertussis fimbriae 2/3 vaccine, inactivated 0.01 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.006 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.02 MG/ML / diphtheria toxoid vaccine, inactivated 30 UNT/ML / tetanus toxoid vaccine, inactivated 10 UNT/ML Injection [Daptacel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300206", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.01 MG/ML / Bordetella pertussis fimbriae 2/3 vaccine, inactivated 0.01 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.006 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.005 MG/ML / diphtheria toxoid vaccine, inactivated 4 UNT/ML / tetanus toxoid vaccine, inactivated 10 UNT/ML Injection [Adacel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1300191", "drug_name": "0.5 ML Bordetella pertussis filamentous hemagglutinin vaccine, inactivated 0.01 MG/ML / Bordetella pertussis fimbriae 2/3 vaccine, inactivated 0.01 MG/ML / Bordetella pertussis pertactin vaccine, inactivated 0.006 MG/ML / Bordetella pertussis toxoid vaccine, inactivated 0.005 MG/ML / diphtheria toxoid vaccine, inactivated 4 UNT/ML / tetanus toxoid vaccine, inactivated 10 UNT/ML Prefilled Syringe [Adacel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299917", "drug_name": "tiagabine hydrochloride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299911", "drug_name": "tiagabine hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299909", "drug_name": "tiagabine hydrochloride 16 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299903", "drug_name": "tiagabine hydrochloride 12 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299897", "drug_name": "moexipril hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1299896", "drug_name": "moexipril hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298910", "drug_name": "molindone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298906", "drug_name": "molindone hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298816", "drug_name": "molindone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1297757", "drug_name": "betaxolol hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1297753", "drug_name": "betaxolol hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1297278", "drug_name": "lurasidone hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1294619", "drug_name": "bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1293504", "drug_name": "caffeine 100 MG / ergotamine tartrate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1292459", "drug_name": "0.5 ML varicella-zoster virus vaccine live (Oka-Merck) strain 2700 UNT/ML Injection [Varivax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1292443", "drug_name": "0.5 ML measles virus vaccine live, Enders' attenuated Edmonston strain 2000 UNT/ML / mumps virus vaccine live, Jeryl Lynn strain 40000 UNT/ML / rubella virus vaccine live (Wistar RA 27-3 strain) 2000 UNT/ML / varicella-zoster virus vaccine live (Oka-Merck) strain 20000 UNT/ML Injection [ProQuad]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1252016", "drug_name": "{21 (desogestrel 0.15 MG / ethinyl estradiol 0.02 MG Oral Tablet) / 5 (ethinyl estradiol 0.01 MG Oral Tablet) / 2 (inert ingredients 1 MG Oral Tablet) } Pack [Viorele 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251336", "drug_name": "{28 (ethinyl estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251334", "drug_name": "{28 (ethinyl estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1250723", "drug_name": "etravirine 25 MG Oral Tablet [Intelence]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1249631", "drug_name": "fluorometholone acetate 1 MG/ML Ophthalmic Suspension [Flarex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246313", "drug_name": "120 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.2 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246310", "drug_name": "120 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.1 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246304", "drug_name": "120 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246288", "drug_name": "120 ACTUAT budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245919", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Marlissa 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245262", "drug_name": "mifepristone 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245001", "drug_name": "eltrombopag 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1244214", "drug_name": "budesonide 3 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243848", "drug_name": "24 HR metformin hydrochloride 500 MG / sitagliptin phosphate 50 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243843", "drug_name": "24 HR metformin hydrochloride 1000 MG / sitagliptin phosphate 50 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243833", "drug_name": "24 HR metformin hydrochloride 1000 MG / sitagliptin phosphate 100 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243585", "drug_name": "flurbiprofen sodium 0.3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243346", "drug_name": "tenofovir disoproxil fumarate 0.04 MG/MG Oral Powder [Viread]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243330", "drug_name": "tenofovir disoproxil fumarate 200 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243326", "drug_name": "tenofovir disoproxil fumarate 150 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243229", "drug_name": "tenofovir disoproxil fumarate 250 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243052", "drug_name": "ivacaftor 150 MG Oral Tablet [Kalydeco]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243040", "drug_name": "linagliptin 2.5 MG / metformin hydrochloride 850 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243033", "drug_name": "linagliptin 2.5 MG / metformin hydrochloride 500 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243026", "drug_name": "linagliptin 2.5 MG / metformin hydrochloride 1000 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243014", "drug_name": "axitinib 5 MG Oral Tablet [Inlyta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243010", "drug_name": "axitinib 1 MG Oral Tablet [Inlyta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242998", "drug_name": "vismodegib 150 MG Oral Capsule [Erivedge]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242787", "drug_name": "{7 (ethinyl estradiol 0.035 MG / norethindrone 0.5 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 0.75 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Alyacen 7/7/7]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242786", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Alyacen 1/35]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242231", "drug_name": "lenalidomide 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1236632", "drug_name": "darunavir 100 MG/ML Oral Suspension [Prezista]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235874", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 0.4 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Philith 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235867", "drug_name": "{7 (ethinyl estradiol 0.035 MG / norethindrone 0.5 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 0.75 MG Oral Tablet) / 7 (ethinyl estradiol 0.035 MG / norethindrone 1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Dasetta 7/7/7 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235595", "drug_name": "raltegravir 25 MG Chewable Tablet [Isentress]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235591", "drug_name": "raltegravir 100 MG Chewable Tablet [Isentress]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235267", "drug_name": "{7 (ethinyl estradiol 0.01 MG Oral Tablet) / 84 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) } Pack [CamreseLo 91 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235247", "drug_name": "lurasidone hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1232088", "drug_name": "rivaroxaban 20 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1232084", "drug_name": "rivaroxaban 15 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1193353", "drug_name": "ruxolitinib 25 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1193349", "drug_name": "ruxolitinib 20 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1193345", "drug_name": "ruxolitinib 15 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1193341", "drug_name": "ruxolitinib 5 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1193337", "drug_name": "ruxolitinib 10 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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"years": [ 2027 ] } ] }, { "rxnorm_id": "1149667", "drug_name": "{7 (ethinyl estradiol 0.01 MG Oral Tablet) / 84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) } Pack [Camrese 91 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1149632", "drug_name": "84 HR estradiol 0.00313 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1149617", "drug_name": "collagenase 0.25 UNT/MG Topical Ointment [Santyl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1148506", "drug_name": "crizotinib 250 MG Oral Capsule [Xalkori]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1148502", "drug_name": "crizotinib 200 MG Oral Capsule [Xalkori]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1148141", "drug_name": "3 ML icatibant 10 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1147334", "drug_name": "emtricitabine 200 MG / rilpivirine 25 MG / tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1147228", "drug_name": "vemurafenib 240 MG Oral Tablet [Zelboraf]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1146690", "drug_name": "24 HR lamotrigine 250 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1145932", "drug_name": "1 ML abatacept 125 MG/ML Prefilled Syringe [Orencia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1120068", "drug_name": "magnesium sulfate 0.0277 MEQ/ML / potassium sulfate 0.0374 MEQ/ML / sodium sulfate 0.257 MEQ/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1119400", "drug_name": "everolimus 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1117531", "drug_name": "chloroquine phosphate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1117522", "drug_name": "colistin 75 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1116758", "drug_name": "chloroquine phosphate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1116635", "drug_name": "ticagrelor 90 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1116150", "drug_name": "bacitracin zinc 0.4 UNT/MG / hydrocortisone acetate 0.01 MG/MG / neomycin sulfate 0.0035 MG/MG / polymyxin B sulfate 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115698", "drug_name": "oseltamivir 6 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115473", "drug_name": "1.5 ML leuprolide acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115468", "drug_name": "1.5 ML leuprolide acetate 15 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115464", "drug_name": "1 ML leuprolide acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115459", "drug_name": "1 ML leuprolide acetate 3.75 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115456", "drug_name": "1 ML leuprolide acetate 15 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115449", "drug_name": "1 ML leuprolide acetate 11.25 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115259", "drug_name": "1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1114466", "drug_name": "nitroglycerin 0.004 MG/MG Rectal Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1114202", "drug_name": "rivaroxaban 10 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1114096", "drug_name": "vandetanib 300 MG Oral Tablet [Caprelsa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1114074", "drug_name": "vandetanib 100 MG Oral Tablet [Caprelsa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1113046", "drug_name": "amylase 15000 UNT / lipase 3000 UNT / protease 9500 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1112715", "drug_name": "{28 (ethinyl estradiol 0.02 MG / levonorgestrel 0.09 MG Oral Tablet) } Pack [Amethyst 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111641", "drug_name": "1 ML glatiramer acetate 20 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111343", "drug_name": "olopatadine 2 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111106", "drug_name": "fidaxomicin 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111018", "drug_name": "sapropterin dihydrochloride 100 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111011", "drug_name": "etonogestrel 68 MG Drug Implant [Nexplanon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1102273", "drug_name": "rilpivirine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1100706", "drug_name": "linagliptin 5 MG Oral Tablet [Tradjenta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1100184", "drug_name": "donepezil hydrochloride 23 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1100075", "drug_name": "abiraterone acetate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1100057", "drug_name": "ciclopirox 80 MG/ML Topical Solution [Ciclodan]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099870", "drug_name": "divalproex sodium 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099687", "drug_name": "valproic acid 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099681", "drug_name": "valproic acid 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099678", "drug_name": "divalproex sodium 250 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099625", "drug_name": "divalproex sodium 125 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099596", "drug_name": "divalproex sodium 125 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099569", "drug_name": "24 HR divalproex sodium 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099563", "drug_name": "24 HR divalproex sodium 250 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099316", "drug_name": "desipramine hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099304", "drug_name": "desipramine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099300", "drug_name": "desipramine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099296", "drug_name": "desipramine hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099292", "drug_name": "desipramine hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1099288", "drug_name": "desipramine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1098678", "drug_name": "nefazodone hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": 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"prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1098608", "drug_name": "24 HR lamotrigine 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1098143", "drug_name": "24 HR niacin 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1098141", "drug_name": "24 HR niacin 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1098134", "drug_name": "24 HR niacin 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1095712", "drug_name": "24 HR nevirapine 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1095362", "drug_name": "{21 (ethinyl estradiol 0.035 MG / norethindrone 0.4 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Balziva 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1095227", "drug_name": "{6 (ethinyl estradiol 0.03 MG / levonorgestrel 0.05 MG Oral Tablet) / 10 (ethinyl 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[ 2027 ] } ] }, { "rxnorm_id": "1091839", "drug_name": "roflumilast 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091652", "drug_name": "azilsartan medoxomil 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091646", "drug_name": "azilsartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091638", "drug_name": "24 HR diltiazem hydrochloride 360 MG Extended Release Oral Tablet [Matzim]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091635", "drug_name": "24 HR diltiazem hydrochloride 300 MG Extended Release Oral Tablet [Matzim]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091632", "drug_name": "24 HR diltiazem hydrochloride 180 MG Extended Release Oral Tablet [Matzim]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091629", "drug_name": "24 HR diltiazem hydrochloride 240 MG Extended Release Oral Tablet [Matzim]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091623", "drug_name": "24 HR diltiazem hydrochloride 420 MG Extended Release Oral Tablet [Matzim]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091497", "drug_name": "methylphenidate hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091392", "drug_name": "methylphenidate hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091341", "drug_name": "methylphenidate hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091339", "drug_name": "clindamycin 10 MG/ML Medicated Pad [Clindacin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091210", "drug_name": "24 HR methylphenidate hydrochloride 54 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091185", "drug_name": "24 HR methylphenidate hydrochloride 36 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091170", "drug_name": "24 HR methylphenidate hydrochloride 27 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091155", "drug_name": "24 HR methylphenidate hydrochloride 18 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1091150", "drug_name": "methylphenidate hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090996", "drug_name": "ethinyl estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet [Jinteli]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090992", "drug_name": "ethinyl estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1088774", "drug_name": "potassium bicarbonate 25 MEQ Effervescent Oral Tablet [Effer-K]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086784", "drug_name": "vilazodone hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086778", "drug_name": "vilazodone hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086772", "drug_name": "vilazodone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085745", "drug_name": "triamcinolone acetonide 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085741", "drug_name": "triamcinolone acetonide 0.25 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085728", "drug_name": "triamcinolone acetonide 0.001 MG/MG Oral Paste", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085686", "drug_name": "triamcinolone acetonide 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085644", "drug_name": "triamcinolone acetonide 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085640", "drug_name": "triamcinolone acetonide 0.005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085636", "drug_name": "triamcinolone acetonide 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1085633", "drug_name": "triamcinolone acetonide 0.00025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1053753", "drug_name": "nystatin 100000 UNT/ML / triamcinolone acetonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1053697", "drug_name": "nystatin 100 UNT/MG / triamcinolone acetonide 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1052658", "drug_name": "etravirine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049686", "drug_name": "oxycodone hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049683", "drug_name": "oxycodone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049635", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049633", "drug_name": "diphenhydramine hydrochloride 50 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049621", "drug_name": "oxycodone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049618", "drug_name": "oxycodone hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049611", "drug_name": "oxycodone hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049604", "drug_name": "oxycodone hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049289", "drug_name": "1 ML diphenhydramine hydrochloride 50 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049227", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 7.5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049225", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049223", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049221", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049216", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 10 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049214", "drug_name": "acetaminophen 325 MG / oxycodone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", 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"FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000153", "drug_name": "1 ML medroxyprogesterone acetate 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000141", "drug_name": "medroxyprogesterone acetate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000135", "drug_name": "medroxyprogesterone acetate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000126", "drug_name": 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000070", "drug_name": "doxepin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000064", "drug_name": "doxepin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000058", "drug_name": "doxepin 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000054", "drug_name": "doxepin 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998675", "drug_name": "168 HR clonidine 0.00833 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998671", "drug_name": "168 HR clonidine 0.00417 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998213", "drug_name": "1 ML morphine sulfate 4 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998189", "drug_name": "everolimus 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "997653", "drug_name": "nilotinib 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "997229", "drug_name": "donepezil hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997226", "drug_name": "donepezil hydrochloride 5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997223", "drug_name": "donepezil hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997220", "drug_name": "donepezil hydrochloride 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997010", "drug_name": "quinine sulfate 324 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "996921", "drug_name": "clozapine 200 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "996615", "drug_name": "24 HR memantine hydrochloride 7 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "996609", "drug_name": "24 HR memantine hydrochloride 28 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "996603", "drug_name": "24 HR memantine hydrochloride 21 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "996594", "drug_name": "24 HR memantine hydrochloride 14 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "996572", "drug_name": "{21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "996571", "drug_name": "memantine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "996561", "drug_name": "memantine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "996559", "drug_name": "1 ML somatropin 12 MG/ML Cartridge [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995666", "drug_name": "meclizine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995624", "drug_name": "meclizine hydrochloride 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995607", "drug_name": "ethambutol hydrochloride 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995599", "drug_name": "ethambutol hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995281", "drug_name": "hydroxyzine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995278", "drug_name": "hydroxyzine pamoate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995258", "drug_name": "hydroxyzine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995253", "drug_name": "hydroxyzine pamoate 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995241", "drug_name": "hydroxyzine hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995232", "drug_name": "hydroxyzine pamoate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995218", "drug_name": "hydroxyzine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "994521", "drug_name": "12 HR orphenadrine citrate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993890", "drug_name": "acetaminophen 300 MG / codeine phosphate 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993856", "drug_name": "lacosamide 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993781", "drug_name": "acetaminophen 300 MG / codeine phosphate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993770", "drug_name": "acetaminophen 300 MG / codeine phosphate 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993755", "drug_name": "acetaminophen 24 MG/ML / codeine phosphate 2.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993691", "drug_name": "bupropion hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993687", "drug_name": "bupropion hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993557", "drug_name": "24 HR bupropion hydrochloride 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993541", "drug_name": "24 HR bupropion hydrochloride 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993536", "drug_name": "12 HR bupropion hydrochloride 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993518", "drug_name": "12 HR bupropion hydrochloride 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993503", "drug_name": "12 HR bupropion hydrochloride 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "993470", "drug_name": "midodrine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993466", "drug_name": "midodrine hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "993462", "drug_name": "midodrine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992475", "drug_name": "promethazine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992459", "drug_name": "promethazine hydrochloride 25 MG Rectal Suppository [Promethegan]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992454", "drug_name": "promethazine hydrochloride 25 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992447", "drug_name": "promethazine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992445", "drug_name": "promethazine hydrochloride 12.5 MG Rectal Suppository [Promethegan]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992441", "drug_name": "promethazine hydrochloride 12.5 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992438", "drug_name": "promethazine hydrochloride 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992432", "drug_name": "promethazine hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992395", "drug_name": "gatifloxacin 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992150", "drug_name": "methenamine hippurate 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991336", "drug_name": "chlorpromazine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991332", "drug_name": "chlorpromazine hydrochloride 30 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991194", "drug_name": "chlorpromazine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991188", "drug_name": "chlorpromazine hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991147", "drug_name": "methadone hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991086", "drug_name": "dicyclomine hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991061", "drug_name": "dicyclomine hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991053", "drug_name": "chlorpromazine hydrochloride 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991044", "drug_name": "chlorpromazine hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "991039", "drug_name": "chlorpromazine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "984105", "drug_name": "sodium phenylbutyrate 0.94 MG/MG Oral Powder", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979492", "drug_name": "losartan potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979485", "drug_name": "losartan potassium 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979480", "drug_name": "losartan potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979471", "drug_name": "hydrochlorothiazide 25 MG / losartan potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979468", "drug_name": "hydrochlorothiazide 12.5 MG / losartan potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979464", "drug_name": "hydrochlorothiazide 12.5 MG / losartan potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979099", "drug_name": "polyethylene glycol 3350 420000 MG / potassium chloride 1480 MG / sodium bicarbonate 5720 MG / sodium chloride 11200 MG Powder for Oral Solution [GaviLyte-N]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979092", "drug_name": "hydroxychloroquine sulfate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978778", "drug_name": "dalteparin sodium 25000 UNT/ML Injectable Solution [Fragmin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978757", "drug_name": "1 ML dalteparin sodium 10000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978747", "drug_name": "0.72 ML dalteparin sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978745", "drug_name": "0.6 ML dalteparin sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978741", "drug_name": "0.5 ML dalteparin sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978737", "drug_name": "0.3 ML dalteparin sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { 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sodium 0.088 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966171", "drug_name": "levothyroxine sodium 0.075 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966170", "drug_name": "levothyroxine sodium 0.075 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966167", "drug_name": "levothyroxine sodium 0.075 MG Oral Tablet [Levo-T]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966164", "drug_name": "levothyroxine sodium 0.05 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966161", "drug_name": "levothyroxine sodium 0.05 MG Oral Tablet [Levo-T]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966158", "drug_name": "levothyroxine sodium 0.025 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "966157", "drug_name": "levothyroxine sodium 0.025 MG Oral 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905377", "drug_name": "hydralazine hydrochloride 37.5 MG / isosorbide dinitrate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905347", "drug_name": "demeclocycline hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905341", "drug_name": "demeclocycline hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905283", "drug_name": "trihexyphenidyl hydrochloride 5 MG Oral Tablet", 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2027 ] } ] }, { "rxnorm_id": "905199", "drug_name": "hydralazine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905172", "drug_name": "protriptyline hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905168", "drug_name": "protriptyline hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905158", "drug_name": "sirolimus 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905100", "drug_name": "{12 (risedronate sodium 35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905092", "drug_name": "{4 (risedronate sodium 35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905064", "drug_name": "triptorelin 11.25 MG Injection [Trelstar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905057", "drug_name": "triptorelin 22.5 MG Injection [Trelstar]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905041", "drug_name": "risedronate sodium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "905028", "drug_name": "risedronate sodium 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905024", "drug_name": "risedronate sodium 35 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904932", "drug_name": "ibandronic acid 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904880", "drug_name": "168 HR buprenorphine 0.005 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904876", "drug_name": "168 HR buprenorphine 0.02 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904870", "drug_name": "168 HR buprenorphine 0.01 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904589", "drug_name": "sotalol hydrochloride 240 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904481", "drug_name": "pravastatin sodium 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904475", "drug_name": "pravastatin sodium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904467", "drug_name": "pravastatin sodium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904458", "drug_name": "pravastatin sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904431", "drug_name": "alendronic acid 70 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "904419", "drug_name": "alendronic acid 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904396", "drug_name": "alendronic acid 35 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904170", "drug_name": "primaquine phosphate 26.3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903891", "drug_name": "fluvoxamine maleate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903887", "drug_name": "fluvoxamine maleate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903884", "drug_name": "fluvoxamine maleate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903857", "drug_name": "pyridostigmine bromide 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903703", "drug_name": "liothyronine sodium 0.05 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903697", "drug_name": "liothyronine sodium 0.025 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "903456", "drug_name": "liothyronine sodium 0.005 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "901614", "drug_name": "aztreonam 75 MG/ML Inhalation Solution [Cayston]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "901518", "drug_name": "0.5 ML Neisseria meningitidis serogroup A oligosaccharide diphtheria CRM197 protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup C oligosaccharide diphtheria CRM197 protein conjugate vaccine 0.01 MG/ML / Neisseria meningitidis serogroup W-135 oligosaccharide diphtheria CRM197 protein conjugate vaccine 0.01 MG/ML / Neisseria meningitidis serogroup Y oligosaccharide diphtheria CRM197 protein conjugate vaccine 0.01 MG/ML Injection [Menveo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "900575", "drug_name": "ritonavir 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "900164", "drug_name": "24 HR lamotrigine 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "900156", "drug_name": "24 HR lamotrigine 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "899557", "drug_name": "dexmethylphenidate hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "899548", "drug_name": "dexmethylphenidate hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "899518", "drug_name": "dexmethylphenidate hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "898723", "drug_name": "benazepril hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898719", "drug_name": "benazepril hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898715", "drug_name": "pregabalin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "898690", "drug_name": "benazepril hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898687", "drug_name": "benazepril hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898490", "drug_name": "potassium citrate 15 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898378", "drug_name": "benazepril hydrochloride 5 MG / hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898372", "drug_name": "benazepril hydrochloride 20 MG / hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898367", "drug_name": "benazepril hydrochloride 20 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898362", "drug_name": "benazepril hydrochloride 10 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898359", "drug_name": "amlodipine 5 MG / benazepril hydrochloride 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898356", "drug_name": "amlodipine 5 MG / benazepril hydrochloride 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898353", "drug_name": "amlodipine 5 MG / benazepril hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898350", "drug_name": "amlodipine 2.5 MG / benazepril hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898346", "drug_name": "amlodipine 10 MG / benazepril hydrochloride 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "898342", "drug_name": "amlodipine 10 MG / benazepril hydrochloride 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897758", "drug_name": "1 ML hydromorphone hydrochloride 4 MG/ML Cartridge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897757", "drug_name": "1 ML hydromorphone hydrochloride 2 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897753", "drug_name": "1 ML hydromorphone hydrochloride 4 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897745", "drug_name": "hydromorphone hydrochloride 2 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897722", "drug_name": "verapamil hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897710", "drug_name": "hydromorphone hydrochloride 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897702", "drug_name": "hydromorphone hydrochloride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897696", "drug_name": "hydromorphone hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897683", "drug_name": "verapamil hydrochloride 80 MG 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897649", "drug_name": "verapamil hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897640", "drug_name": "verapamil hydrochloride 180 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897630", "drug_name": "24 HR verapamil hydrochloride 360 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "897624", "drug_name": "24 HR verapamil hydrochloride 240 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"prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "896766", "drug_name": "labetalol hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "896762", "drug_name": "labetalol hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "896758", "drug_name": "labetalol hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "896273", "drug_name": "120 ACTUAT fluticasone propionate 0.23 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fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "896209", "drug_name": "60 ACTUAT fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "896184", "drug_name": "60 ACTUAT fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "895987", "drug_name": "fluticasone propionate 0.5 MG/ML Topical 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "894859", "drug_name": "acitretin 17.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "894780", "drug_name": "morphine sulfate 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892672", "drug_name": "morphine sulfate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892646", "drug_name": "morphine sulfate 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892625", "drug_name": "morphine sulfate 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892589", "drug_name": "morphine sulfate 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892582", "drug_name": "morphine sulfate 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892255", "drug_name": "levothyroxine sodium 0.3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892251", "drug_name": "levothyroxine sodium 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892246", "drug_name": "levothyroxine sodium 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891893", "drug_name": "morphine sulfate 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891888", "drug_name": "morphine sulfate 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891881", "drug_name": "morphine sulfate 15 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891874", "drug_name": "morphine sulfate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "886671", "drug_name": "flecainide acetate 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "886666", "drug_name": "flecainide acetate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "886662", "drug_name": "flecainide acetate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "885857", "drug_name": "balsalazide disodium 750 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "885219", "drug_name": "benztropine mesylate 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "885213", "drug_name": "benztropine mesylate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "885209", "drug_name": "benztropine mesylate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "884707", "drug_name": "estradiol 0.01 MG Vaginal Insert", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "884617", "drug_name": "eltrombopag 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "884386", "drug_name": "dextroamphetamine sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "884385", "drug_name": "dextroamphetamine sulfate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "884308", "drug_name": "nystatin 100 UNT/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "884189", "drug_name": "clonidine hydrochloride 0.3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "884185", "drug_name": "clonidine hydrochloride 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "884173", "drug_name": "clonidine hydrochloride 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "883826", "drug_name": "tranexamic acid 650 MG Oral Tablet", 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"drug_name": "metoprolol tartrate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866910", "drug_name": "colesevelam hydrochloride 625 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866514", "drug_name": "metoprolol tartrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866511", "drug_name": "metoprolol tartrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866436", "drug_name": "24 HR metoprolol succinate 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866427", "drug_name": "24 HR metoprolol succinate 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866419", "drug_name": "24 HR metoprolol succinate 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866412", "drug_name": "24 HR metoprolol succinate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866144", "drug_name": "cyproheptadine hydrochloride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866111", "drug_name": "buspirone hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866103", "drug_name": "24 HR paliperidone 1.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "866094", "drug_name": "buspirone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866090", "drug_name": "buspirone hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866083", "drug_name": "buspirone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "866049", "drug_name": "60 ACTUAT salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Serevent]", 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} ] }, { "rxnorm_id": "865212", "drug_name": "24 HR selegiline 0.375 MG/HR Transdermal System [Emsam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "865208", "drug_name": "24 HR selegiline 0.25 MG/HR Transdermal System [Emsam]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "865155", "drug_name": "bisoprolol fumarate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "865129", "drug_name": "fluphenazine hydrochloride 2.5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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"drug_name": "methadone hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864761", "drug_name": "methadone hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864718", "drug_name": "methadone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864706", "drug_name": "methadone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864681", "drug_name": "atovaquone 62.5 MG / proguanil hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864675", "drug_name": "atovaquone 250 MG / proguanil hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "864661", "drug_name": "efavirenz 600 MG / lamivudine 300 MG / tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "864650", "drug_name": "ganciclovir 0.0015 MG/MG Ophthalmic Gel [Zirgan]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863841", "drug_name": "amylase 60000 UNT / lipase 12000 UNT / protease 38000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863836", "drug_name": "amylase 30000 UNT / lipase 6000 UNT / protease 19000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863829", "drug_name": "amylase 120000 UNT / lipase 24000 UNT / protease 76000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863669", "drug_name": "tamsulosin hydrochloride 0.4 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "863664", "drug_name": "oxybutynin chloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863636", "drug_name": "24 HR oxybutynin chloride 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863628", "drug_name": "24 HR oxybutynin chloride 15 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863619", "drug_name": "24 HR oxybutynin chloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863599", "drug_name": "oxybutynin chloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "863559", "drug_name": "valganciclovir 50 MG/ML Oral 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "862006", "drug_name": "24 HR guanfacine 1 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861960", "drug_name": "armodafinil 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861848", "drug_name": "fluphenazine hydrochloride 5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861822", "drug_name": "metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861821", "drug_name": "metformin hydrochloride 500 MG / sitagliptin phosphate 50 MG Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861783", "drug_name": "metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861771", "drug_name": "metformin hydrochloride 1000 MG / sitagliptin phosphate 50 MG Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861753", "drug_name": "glyburide 5 MG / metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861748", "drug_name": "glyburide 2.5 MG / metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861743", "drug_name": "glyburide 1.25 MG / metformin hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861740", "drug_name": "glipizide 5 MG / metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861736", "drug_name": "glipizide 2.5 MG / metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861731", "drug_name": "glipizide 2.5 MG / metformin hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861668", "drug_name": "dihydroergotamine mesylate 0.5 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861657", "drug_name": "24 HR nitroglycerin 0.1 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861652", "drug_name": "pitavastatin calcium 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861648", "drug_name": "pitavastatin calcium 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861643", 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"drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861597", "drug_name": "pentamidine isethionate 50 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861495", "drug_name": "clobetasol propionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861490", "drug_name": "clobetasol propionate 0.5 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861487", 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true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861356", "drug_name": "0.8 ML fondaparinux sodium 12.5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861353", "drug_name": "clobetasol propionate 0.5 MG/ML Topical Foam", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861237", "drug_name": "24 HR amphetamine aspartate 1.25 MG / amphetamine sulfate 1.25 MG / dextroamphetamine saccharate 1.25 MG / dextroamphetamine sulfate 1.25 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861232", "drug_name": "24 HR amphetamine aspartate 7.5 MG / amphetamine sulfate 7.5 MG / dextroamphetamine saccharate 7.5 MG / dextroamphetamine sulfate 7.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861227", "drug_name": "24 HR amphetamine aspartate 6.25 MG / amphetamine sulfate 6.25 MG / dextroamphetamine saccharate 6.25 MG / dextroamphetamine sulfate 6.25 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861225", "drug_name": "24 HR amphetamine aspartate 5 MG / amphetamine sulfate 5 MG / dextroamphetamine saccharate 5 MG / dextroamphetamine sulfate 5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861223", "drug_name": "24 HR amphetamine aspartate 3.75 MG / amphetamine sulfate 3.75 MG / dextroamphetamine saccharate 3.75 MG / dextroamphetamine sulfate 3.75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861221", "drug_name": "24 HR amphetamine aspartate 2.5 MG / amphetamine sulfate 2.5 MG / dextroamphetamine saccharate 2.5 MG / dextroamphetamine sulfate 2.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861204", "drug_name": "brimonidine tartrate 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861200", "drug_name": "brimonidine tartrate 2 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861171", "drug_name": "12 HR propafenone hydrochloride 425 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861164", "drug_name": "12 HR propafenone hydrochloride 325 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861156", "drug_name": "12 HR propafenone hydrochloride 225 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861132", "drug_name": "24 HR alfuzosin hydrochloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861064", "drug_name": "sertraline 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861010", "drug_name": "metformin hydrochloride 850 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861007", "drug_name": "metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861004", "drug_name": "metformin hydrochloride 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860981", "drug_name": "24 HR metformin hydrochloride 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860975", "drug_name": "24 HR metformin hydrochloride 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860918", "drug_name": "fluphenazine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860901", "drug_name": "galantamine hydrobromide 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860805", "drug_name": "azelastine hydrochloride 0.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860715", "drug_name": "24 HR galantamine hydrobromide 8 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860707", "drug_name": "24 HR galantamine hydrobromide 24 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860695", "drug_name": "24 HR galantamine hydrobromide 16 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860225", "drug_name": "megestrol acetate 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860221", "drug_name": "megestrol acetate 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860215", "drug_name": "megestrol acetate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860115", "drug_name": "2 ML ketorolac tromethamine 30 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860114", "drug_name": "1 ML ketorolac tromethamine 30 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860113", "drug_name": "1 ML ketorolac tromethamine 15 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860107", "drug_name": "ketorolac tromethamine 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860103", "drug_name": "ketorolac tromethamine 4 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "860092", "drug_name": "1 ML ketorolac tromethamine 15 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859981", "drug_name": "asenapine 5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "859975", "drug_name": "asenapine 10 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "859871", "drug_name": "haloperidol decanoate 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859867", "drug_name": "haloperidol decanoate 50 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859841", "drug_name": "fluphenazine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859835", "drug_name": "fluphenazine hydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859824", "drug_name": "fluphenazine decanoate 25 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859751", "drug_name": "rosuvastatin calcium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859747", "drug_name": "rosuvastatin calcium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859424", "drug_name": "rosuvastatin calcium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859419", "drug_name": "rosuvastatin calcium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859193", "drug_name": "selegiline hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859186", "drug_name": "selegiline hydrochloride 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859052", "drug_name": "pramipexole dihydrochloride 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859048", "drug_name": "pramipexole dihydrochloride 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859044", "drug_name": "pramipexole dihydrochloride 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859040", "drug_name": "pramipexole dihydrochloride 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "859033", "drug_name": "pramipexole dihydrochloride 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858828", "drug_name": "enalapril maleate 10 MG / hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858824", "drug_name": "enalapril maleate 5 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858817", "drug_name": "enalapril maleate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858813", "drug_name": "enalapril maleate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858810", "drug_name": "enalapril maleate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858804", "drug_name": "enalapril maleate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858751", "drug_name": "ursodiol 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858747", "drug_name": "ursodiol 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858733", "drug_name": "ursodiol 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858625", "drug_name": "pramipexole dihydrochloride 0.75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858127", "drug_name": "degarelix 120 MG Injection [Firmagon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858125", "drug_name": "degarelix 80 MG Injection [Firmagon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858074", "drug_name": "0.25 ML paliperidone palmitate 156 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858057", "drug_name": "0.75 ML paliperidone palmitate 156 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858055", "drug_name": "1 ML paliperidone palmitate 156 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858053", "drug_name": "1.5 ML paliperidone palmitate 156 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "858051", "drug_name": "0.5 ML paliperidone palmitate 156 MG/ML Prefilled Syringe [Invega]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "857700", "drug_name": "diclofenac sodium 15 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "857564", "drug_name": "24 HR trospium chloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857560", "drug_name": "trospium chloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857391", "drug_name": "acetaminophen 325 MG / hydrocodone bitartrate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857366", "drug_name": "econazole nitrate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "857340", "drug_name": "bethanechol chloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857336", "drug_name": "bethanechol chloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857328", "drug_name": "bethanechol chloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857321", "drug_name": "bethanechol chloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857305", "drug_name": "clomipramine hydrochloride 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857301", "drug_name": "clomipramine hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857297", "drug_name": "clomipramine hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857224", "drug_name": "sevelamer hydrochloride 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857216", "drug_name": "sevelamer hydrochloride 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857187", "drug_name": "fosinopril sodium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857183", "drug_name": "fosinopril sodium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857174", "drug_name": "fosinopril sodium 20 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857169", "drug_name": "fosinopril sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857166", "drug_name": "fosinopril sodium 10 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857005", "drug_name": "acetaminophen 325 MG / hydrocodone bitartrate 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857002", "drug_name": "acetaminophen 325 MG / hydrocodone bitartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856999", "drug_name": "acetaminophen 325 MG / hydrocodone bitartrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856940", "drug_name": "acetaminophen 21.7 MG/ML / hydrocodone bitartrate 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856853", "drug_name": "amitriptyline hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856845", "drug_name": "amitriptyline hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856834", "drug_name": "amitriptyline hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856783", "drug_name": "amitriptyline hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856773", "drug_name": "amitriptyline hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856762", "drug_name": "amitriptyline hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856666", "drug_name": "rifaximin 550 MG Oral Tablet [XIFAXAN]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "856660", "drug_name": "dantrolene sodium 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856656", "drug_name": "dantrolene sodium 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856652", "drug_name": "dantrolene sodium 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856578", "drug_name": "propranolol hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856569", "drug_name": "24 HR propranolol hydrochloride 80 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856556", "drug_name": "propranolol hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856535", "drug_name": "24 HR propranolol hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856519", "drug_name": "propranolol hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856481", "drug_name": "24 HR propranolol hydrochloride 160 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856460", "drug_name": "24 HR propranolol hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856457", "drug_name": "propranolol hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856448", "drug_name": "propranolol hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856377", "drug_name": "trazodone hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856373", "drug_name": "trazodone hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "856364", "drug_name": "trazodone hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855942", "drug_name": "diclofenac potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855926", "drug_name": "diclofenac sodium 75 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855906", "drug_name": "diclofenac sodium 50 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855875", "drug_name": "phenytoin sodium 300 MG Extended Release Oral Capsule [Phenytek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855873", "drug_name": "phenytoin sodium 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855871", "drug_name": "phenytoin sodium 30 MG Extended Release Oral Capsule [Dilantin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855863", "drug_name": "phenytoin sodium 200 MG Extended Release Oral Capsule [Phenytek]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855861", "drug_name": "phenytoin sodium 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855818", "drug_name": "prasugrel 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855812", "drug_name": "prasugrel 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855671", "drug_name": "phenytoin sodium 100 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855664", "drug_name": "diclofenac sodium 25 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855657", "drug_name": "24 HR diclofenac sodium 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855642", "drug_name": "diclofenac sodium 0.03 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "855480", "drug_name": "alclometasone dipropionate 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855474", "drug_name": "alclometasone dipropionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855348", "drug_name": "warfarin sodium 7.5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855344", "drug_name": "warfarin sodium 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855342", "drug_name": "warfarin sodium 6 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855338", "drug_name": "warfarin sodium 6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855336", "drug_name": "warfarin sodium 5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855332", "drug_name": "warfarin sodium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855328", "drug_name": "warfarin sodium 4 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855324", "drug_name": "warfarin sodium 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855322", "drug_name": "warfarin sodium 3 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855318", "drug_name": "warfarin sodium 3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855316", "drug_name": "warfarin sodium 2.5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855312", "drug_name": "warfarin sodium 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855306", "drug_name": "warfarin sodium 2 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855302", "drug_name": "warfarin sodium 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855300", "drug_name": "warfarin sodium 10 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855296", "drug_name": "warfarin sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855292", "drug_name": "warfarin sodium 1 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855288", "drug_name": "warfarin sodium 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855194", "drug_name": "tolterodine tartrate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855189", "drug_name": "24 HR tolterodine tartrate 4 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855182", "drug_name": "24 HR tolterodine tartrate 2 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855178", "drug_name": "tolterodine tartrate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855172", "drug_name": "levocetirizine dihydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854988", "drug_name": "perindopril erbumine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854984", "drug_name": "perindopril erbumine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854925", "drug_name": "perindopril erbumine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854919", "drug_name": "bisoprolol fumarate 5 MG / hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854916", "drug_name": "bisoprolol fumarate 2.5 MG / hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854908", "drug_name": "bisoprolol fumarate 10 MG / hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854905", "drug_name": "bisoprolol fumarate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854901", "drug_name": "bisoprolol fumarate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854894", "drug_name": "zolpidem tartrate 6.25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854880", "drug_name": "zolpidem tartrate 12.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854876", "drug_name": "zolpidem tartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854873", "drug_name": "zolpidem tartrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854868", "drug_name": "rabeprazole sodium 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854859", "drug_name": "dronedarone 400 MG Oral Tablet [Multaq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854801", "drug_name": "diclofenac sodium 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854255", "drug_name": "enoxaparin sodium 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854252", "drug_name": "1 ML enoxaparin sodium 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854248", "drug_name": "1 ML enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854245", "drug_name": "0.8 ML enoxaparin sodium 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854241", "drug_name": "0.8 ML enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854238", "drug_name": "0.6 ML enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854235", "drug_name": "0.4 ML enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "854228", "drug_name": "0.3 ML enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "853201", "drug_name": "24 HR quetiapine 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "852913", "drug_name": "quinidine sulfate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "852877", "drug_name": "quinidine sulfate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "850457", "drug_name": "darunavir 150 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "850309", "drug_name": "besifloxacin 6 MG/ML Ophthalmic Suspension [Besivance]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "850091", "drug_name": "24 HR lamotrigine 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "850087", "drug_name": "24 HR lamotrigine 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849515", "drug_name": "desmopressin acetate 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849506", "drug_name": "desmopressin acetate 0.01 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849431", "drug_name": "naproxen sodium 550 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849398", "drug_name": "naproxen sodium 275 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849389", "drug_name": "amantadine hydrochloride 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849385", "drug_name": "amantadine hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848951", "drug_name": "Sugar-Free cholestyramine resin 4000 MG Powder for Oral Suspension [Prevalite]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848943", "drug_name": "cholestyramine resin 4000 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848752", "drug_name": "{2 (iloperidone 1 MG Oral Tablet [Fanapt]) / 2 (iloperidone 2 MG Oral Tablet [Fanapt]) / 2 (iloperidone 4 MG Oral Tablet [Fanapt]) / 2 (iloperidone 6 MG Oral Tablet [Fanapt]) } Pack [Fanapt Titration Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848750", "drug_name": "iloperidone 8 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848746", "drug_name": "iloperidone 6 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848742", "drug_name": "iloperidone 4 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848738", "drug_name": "iloperidone 2 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848734", "drug_name": "iloperidone 12 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848730", "drug_name": "iloperidone 10 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848726", "drug_name": "iloperidone 1 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848582", "drug_name": "24 HR ropinirole 6 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848330", "drug_name": "90 DAY estradiol 0.000313 MG/HR Vaginal System [Estring]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "848208", "drug_name": "Augmented betamethasone 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848180", "drug_name": "Augmented betamethasone 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848178", "drug_name": "Augmented betamethasone 0.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848176", "drug_name": "Augmented betamethasone 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847749", "drug_name": "lopinavir 80 MG/ML / ritonavir 20 MG/ML Oral Solution [Kaletra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "847734", "drug_name": "artemether 20 MG / lumefantrine 120 MG Oral Tablet [Coartem]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847254", "drug_name": "3 ML insulin lispro 25 UNT/ML / insulin lispro protamine, human 75 UNT/ML Pen Injector [Humalog Mix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847232", "drug_name": "3 ML insulin glargine 100 UNT/ML Pen Injector [Lantus]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847213", "drug_name": "3 ML insulin lispro 50 UNT/ML / insulin lispro protamine, human 50 UNT/ML Pen Injector [Humalog Mix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847199", "drug_name": "3 ML insulin isophane, human 100 UNT/ML Pen Injector [Humulin N]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847189", "drug_name": "3 ML insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Pen Injector [Humulin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "846378", "drug_name": "24 HR levetiracetam 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "845515", "drug_name": "everolimus 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "845507", "drug_name": "everolimus 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "845488", "drug_name": "ramipril 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "836636", "drug_name": "0.5 ML hepatitis A virus strain CR 326F antigen, inactivated 50 UNT/ML Prefilled Syringe [Vaqta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "836634", "drug_name": "1 ML hepatitis A virus strain CR 326F antigen, inactivated 50 UNT/ML Prefilled Syringe [Vaqta]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "836395", "drug_name": "acetaminophen 325 MG / tramadol hydrochloride 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "836358", "drug_name": "ipratropium bromide 0.2 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "836343", "drug_name": "200 ACTUAT ipratropium bromide 0.017 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "835958", "drug_name": "amiodarone hydrochloride 100 MG Oral Tablet [Pacerone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835956", "drug_name": "amiodarone hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835925", "drug_name": "cyclosporine, modified 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835913", "drug_name": "mefloquine hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835896", "drug_name": "cyclosporine, modified 25 MG Oral Capsule [Gengraf]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835894", "drug_name": "cyclosporine, modified 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835886", "drug_name": "cyclosporine, modified 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835840", "drug_name": "testosterone cypionate 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "835835", "drug_name": "cyclosporine, modified 100 MG Oral Capsule [Gengraf]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835829", "drug_name": "testosterone cypionate 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "835809", "drug_name": "testosterone enanthate 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "835726", "drug_name": "acamprosate calcium 333 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835603", "drug_name": "tramadol hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835593", "drug_name": "imipramine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835568", "drug_name": "imipramine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "835564", "drug_name": "imipramine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834348", "drug_name": "amiodarone hydrochloride 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834346", "drug_name": "amiodarone hydrochloride 200 MG Oral Tablet [Pacerone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834241", "drug_name": "febuxostat 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834235", "drug_name": "febuxostat 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834137", "drug_name": "chlorhexidine gluconate 1.2 MG/ML Mouthwash [Periogard]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834127", "drug_name": "chlorhexidine gluconate 1.2 MG/ML Mouthwash", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834102", "drug_name": "penicillin V potassium 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834061", "drug_name": "penicillin V potassium 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834046", "drug_name": "penicillin V potassium 25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834040", "drug_name": "penicillin V potassium 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "834022", "drug_name": "ketorolac tromethamine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833528", "drug_name": "amiodarone hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "833217", "drug_name": "diltiazem hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "833151", "drug_name": "{5 (milnacipran hydrochloride 12.5 MG Oral Tablet [Savella]) / 8 (milnacipran hydrochloride 25 MG Oral Tablet [Savella]) / 42 (milnacipran hydrochloride 50 MG Oral Tablet [Savella]) } Pack [Savella 4-Week Titration]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833150", "drug_name": "{5 (milnacipran hydrochloride 12.5 MG Oral Tablet) / 8 (milnacipran hydrochloride 25 MG Oral Tablet) / 42 (milnacipran hydrochloride 50 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833149", "drug_name": "milnacipran hydrochloride 25 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833147", "drug_name": "milnacipran hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833146", "drug_name": "milnacipran hydrochloride 50 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833144", "drug_name": "milnacipran hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833143", "drug_name": "milnacipran hydrochloride 12.5 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833141", "drug_name": "milnacipran hydrochloride 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833139", "drug_name": "milnacipran hydrochloride 100 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833135", "drug_name": "milnacipran hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "833008", "drug_name": "desmopressin acetate 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "832731", "drug_name": "Microencapsulated potassium chloride 15 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "832718", "drug_name": "potassium chloride 8 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831872", "drug_name": "{21 (desogestrel 0.15 MG / ethinyl estradiol 0.02 MG Oral Tablet) / 5 (ethinyl estradiol 0.01 MG Oral Tablet) / 2 (inert ingredients 1 MG Oral Tablet) } Pack [Azurette 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831870", "drug_name": "darunavir 75 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "831533", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Errin 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831359", "drug_name": "24 HR diltiazem hydrochloride 420 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831338", "drug_name": "24 HR diltiazem hydrochloride 300 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831309", "drug_name": "24 HR diltiazem hydrochloride 240 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831285", "drug_name": "24 HR diltiazem hydrochloride 240 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831261", "drug_name": "cromolyn sodium 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831255", "drug_name": "24 HR diltiazem hydrochloride 180 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831252", "drug_name": "24 HR diltiazem hydrochloride 180 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831246", "drug_name": "cromolyn sodium 10 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831226", "drug_name": "24 HR diltiazem hydrochloride 120 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831215", "drug_name": "24 HR diltiazem hydrochloride 120 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831109", "drug_name": "cromolyn sodium 40 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831103", "drug_name": "diltiazem hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831102", "drug_name": "diltiazem hydrochloride 90 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "831054", "drug_name": "diltiazem hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830900", "drug_name": "24 HR diltiazem hydrochloride 420 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830897", "drug_name": "24 HR diltiazem hydrochloride 360 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830882", "drug_name": "24 HR diltiazem hydrochloride 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830879", "drug_name": "24 HR diltiazem hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830877", "drug_name": "24 HR diltiazem hydrochloride 180 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830874", "drug_name": "24 HR diltiazem hydrochloride 120 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830872", "drug_name": "12 HR diltiazem hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830869", "drug_name": "12 HR diltiazem hydrochloride 90 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830865", "drug_name": "12 HR diltiazem hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830861", "drug_name": "24 HR diltiazem hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830845", "drug_name": "24 HR diltiazem hydrochloride 180 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830837", "drug_name": "24 HR diltiazem hydrochloride 240 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830801", "drug_name": "24 HR diltiazem hydrochloride 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830795", "drug_name": "24 HR diltiazem hydrochloride 360 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830557", "drug_name": "0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [Kinrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830470", "drug_name": "1 ML rabies virus vaccine wistar strain PM-1503-3M (human), inactivated 2.5 UNT/ML Injection [Imovax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830463", "drug_name": "1 ML rabies virus vaccine flury-lep strain 2.5 UNT/ML Injection [RabAvert]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830263", "drug_name": "1 ML hepatitis B surface antigen vaccine 0.04 MG/ML Injection [Recombivax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830253", "drug_name": "0.5 ML hepatitis B surface antigen vaccine 0.01 MG/ML Prefilled Syringe [Recombivax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "830245", "drug_name": "1 ML hepatitis B surface antigen vaccine 0.01 MG/ML Prefilled Syringe [Recombivax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "829989", "drug_name": "0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "829762", "drug_name": "10 ML magnesium sulfate 500 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828755", "drug_name": "caspofungin acetate 50 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828539", "drug_name": "caspofungin acetate 70 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828379", "drug_name": "fenofibric acid 45 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828373", "drug_name": "fenofibric acid 135 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828348", "drug_name": "cyclobenzaprine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "828320", "drug_name": "cyclobenzaprine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "828248", "drug_name": "cortisone acetate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "827073", "drug_name": "nebivolol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "826612", "drug_name": "silodosin 4 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "825427", "drug_name": "eltrombopag 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "825421", "drug_name": "eltrombopag 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "825159", "drug_name": "0.5 ML hepatitis B immune globulin 220 UNT/ML Prefilled Syringe [Hyperhep B]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "825130", "drug_name": "24 HR mesalamine 375 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "824959", "drug_name": "24 HR ropinirole 12 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "824301", "drug_name": "rufinamide 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "824295", "drug_name": "rufinamide 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "810096", "drug_name": "{7 (ethinyl estradiol 0.01 MG Oral Tablet) / 84 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "810077", "drug_name": "24 HR fesoterodine fumarate 8 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "810071", "drug_name": "24 HR fesoterodine fumarate 4 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "810000", "drug_name": "lacosamide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809996", "drug_name": "lacosamide 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809992", "drug_name": "lacosamide 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809987", "drug_name": "lacosamide 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809871", "drug_name": "C1 esterase inhibitor (human) 500 UNT Injection [Cinryze]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809477", "drug_name": "silodosin 8 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "809159", "drug_name": "0.5 ML etanercept 50 MG/ML Prefilled Syringe [Enbrel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "808917", "drug_name": "fosfomycin 3000 MG Granules for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "807832", "drug_name": "24 HR levetiracetam 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "807225", "drug_name": "typhoid Vi polysaccharide vaccine, S typhi Ty2 strain 0.05 MG/ML Injectable Solution [Typhim VI]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "805464", "drug_name": "tetrabenazine 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "804186", "drug_name": "0.5 ML measles virus vaccine live, Enders' attenuated Edmonston strain 2000 UNT/ML / mumps virus vaccine live, Jeryl Lynn strain 25000 UNT/ML / rubella virus vaccine live (Wistar RA 27-3 strain) 2000 UNT/ML Injection [M-M-R II]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "803371", "drug_name": "1 ML hepatitis A vaccine (inactivated) strain HM175 720 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML Prefilled Syringe [Twinrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "802749", "drug_name": "candesartan cilexetil 32 MG / hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "802652", "drug_name": "1 ML etanercept 50 MG/ML Prefilled Syringe [Enbrel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "801966", "drug_name": "4 ML diazepam 5 MG/ML Rectal Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "801961", "drug_name": "2 ML diazepam 5 MG/ML Rectal Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "801957", "drug_name": "0.5 ML diazepam 5 MG/ML Rectal Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "801054", "drug_name": "polyethylene glycol 3350 420000 MG / potassium chloride 1480 MG / sodium bicarbonate 5720 MG / sodium chloride 11200 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "800345", "drug_name": "alanine 6.98 MG/ML / arginine 12.3 MG/ML / aspartate 5.27 MG/ML / glutamate 8.2 MG/ML / glycine 3.85 MG/ML / histidine 3.12 MG/ML / isoleucine 7.6 MG/ML / leucine 12 MG/ML / lysine 6.77 MG/ML / methionine 1.8 MG/ML / phenylalanine 4.27 MG/ML / proline 8.12 MG/ML / serine 4.95 MG/ML / taurine 0.7 MG/ML / threonine 5.12 MG/ML / tryptophan 1.8 MG/ML / tyrosine 0.44 MG/ML / valine 6.73 MG/ML Injectable Solution [Aminosyn-PF 10 %, Sulfite-Free]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "800241", "drug_name": "alanine 9.93 MG/ML / arginine 10.2 MG/ML / aspartate 7 MG/ML / glutamate 7.38 MG/ML / glycine 5 MG/ML / histidine 3 MG/ML / isoleucine 6.6 MG/ML / leucine 10 MG/ML / lysine 10.5 MG/ML / methionine 1.72 MG/ML / phenylalanine 2.98 MG/ML / proline 7.22 MG/ML / serine 5.3 MG/ML / threonine 4 MG/ML / tryptophan 2 MG/ML / tyrosine 2.7 MG/ML / valine 5 MG/ML Injectable Solution [Aminosyn II 10 %]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "800192", "drug_name": "alanine 14.9 MG/ML / arginine 15.3 MG/ML / aspartate 10.5 MG/ML / glutamate 11.1 MG/ML / glycine 7.5 MG/ML / histidine 4.5 MG/ML / isoleucine 9.9 MG/ML / leucine 15 MG/ML / lysine 15.8 MG/ML / methionine 2.58 MG/ML / phenylalanine 4.47 MG/ML / proline 10.8 MG/ML / serine 7.95 MG/ML / threonine 6 MG/ML / tryptophan 3 MG/ML / tyrosine 4.05 MG/ML / valine 7.5 MG/ML Injectable Solution [Aminosyn II 15%]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "799056", "drug_name": "24 HR ropinirole 4 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "799055", "drug_name": "24 HR ropinirole 2 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "799054", "drug_name": "24 HR ropinirole 8 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "799047", "drug_name": "dasatinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "798482", "drug_name": "0.5 ML hepatitis A vaccine (inactivated) strain HM175 1440 UNT/ML Prefilled Syringe [Havrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798479", "drug_name": "1 ML hepatitis A vaccine (inactivated) strain HM175 1440 UNT/ML Prefilled Syringe [Havrix]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798451", "drug_name": "0.5 ML Haemophilus influenzae b (Ross strain) capsular polysaccharide meningococcal protein conjugate vaccine 0.265 MG/ML Injection [PedvaxHIB]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798430", "drug_name": "0.5 ML hepatitis B surface antigen vaccine 0.02 MG/ML Prefilled Syringe [Engerix-B]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798428", "drug_name": "1 ML hepatitis B surface antigen vaccine 0.02 MG/ML Prefilled Syringe [Engerix-B]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798300", "drug_name": "human-bovine reassortant rotavirus strain G1 vaccine 1100000 UNT/ML / human-bovine reassortant rotavirus strain G2 vaccine 1400000 UNT/ML / human-bovine reassortant rotavirus strain G3 vaccine 1100000 UNT/ML / human-bovine reassortant rotavirus strain G4 vaccine 1000000 UNT/ML / human-bovine reassortant rotavirus strain P1A[8] vaccine 1150000 UNT/ML Oral Suspension [RotaTeq]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "798133", "drug_name": "erythromycin 20 MG/ML Medicated Pad [Ery]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "797544", "drug_name": "isopropyl alcohol 0.7 ML/ML Medicated Pad", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "797274", "drug_name": "clindamycin 10 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "794639", "drug_name": "lubiprostone 0.008 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "793741", "drug_name": "sodium polystyrene sulfonate 250 MG/ML Oral Suspension [Kionex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "790284", "drug_name": "30 ACTUAT mometasone furoate 0.11 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "789980", "drug_name": "ampicillin 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763489", "drug_name": "1 ML somatropin 5 MG/ML Cartridge [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763185", "drug_name": "{21 (prednisone 10 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763183", "drug_name": "{48 (prednisone 10 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763181", "drug_name": "{21 (prednisone 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763179", "drug_name": "{48 (prednisone 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763106", "drug_name": "poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML Injectable Suspension [Ipol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762897", "drug_name": "0.25 ML somatropin 8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762875", "drug_name": "0.25 ML somatropin 4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762868", "drug_name": "0.25 ML somatropin 7.2 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762859", "drug_name": "0.25 ML somatropin 6.4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762852", "drug_name": "0.25 ML somatropin 5.6 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762849", "drug_name": "0.25 ML somatropin 4.8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762843", "drug_name": "0.25 ML somatropin 3.2 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762839", "drug_name": "0.25 ML somatropin 2.4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762836", "drug_name": "0.25 ML somatropin 1.6 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762833", "drug_name": "0.25 ML somatropin 0.8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762675", "drug_name": "{21 (methylprednisolone 4 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "762663", "drug_name": "{84 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Jolessa 91 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "762602", "drug_name": "Salmonella typhi Ty21a live antigen 2000000000 UNT Delayed Release Oral Capsule 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "756059", "drug_name": "lithium citrate 60 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "755470", "drug_name": "lactulose 667 MG/ML Oral Solution [Enulose]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "754761", "drug_name": "etravirine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "754508", "drug_name": "{1 (aprepitant 125 MG Oral Capsule) / 2 (aprepitant 80 MG Oral Capsule) } Pack", "plans": [ { "plan_id_type": 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"drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748977", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Nora-BE 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748962", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack [Camila 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748961", "drug_name": "{28 (norethindrone 0.35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748879", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack [Levora 0.15/30 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748878", "drug_name": "{21 (ethinyl estradiol 0.03 MG / levonorgestrel 0.15 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "748868", "drug_name": "{21 (ethinyl estradiol 0.02 MG / levonorgestrel 0.1 MG Oral Tablet) / 7 (inert ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, 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"rxnorm_id": "688242", "drug_name": "estrogens, conjugated (USP) 0.625 MG/ML Vaginal Cream [Premarin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "687043", "drug_name": "amphetamine aspartate 3.125 MG / amphetamine sulfate 3.125 MG / dextroamphetamine saccharate 3.125 MG / dextroamphetamine sulfate 3.125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "686924", "drug_name": "carvedilol 3.125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "686429", "drug_name": "mesalamine 1200 MG Delayed 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"quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "672569", "drug_name": "24 HR paliperidone 6 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "672567", "drug_name": "24 HR paliperidone 3 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "672149", "drug_name": "lapatinib 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "670026", "drug_name": "darunavir 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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"sitagliptin phosphate 25 MG Oral Tablet [Januvia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "665036", "drug_name": "sitagliptin phosphate 100 MG Oral Tablet [Januvia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "665019", "drug_name": "posaconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "664741", "drug_name": "atazanavir 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "646456", "drug_name": "nystatin 100 UNT/MG Topical Powder", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "645037", "drug_name": "risperidone 0.25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "644304", "drug_name": "tamoxifen 2 MG/ML Oral Solution [Soltamox]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "644088", "drug_name": "aprepitant 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "643720", "drug_name": "lenalidomide 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "643712", "drug_name": "lenalidomide 15 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "643488", "drug_name": "isotretinoin 30 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "643109", "drug_name": "dasatinib 70 MG Oral Tablet", "plans": [ 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} ] }, { "rxnorm_id": "643022", "drug_name": "aripiprazole 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "643019", "drug_name": "aripiprazole 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "639537", "drug_name": "candesartan cilexetil 32 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "637549", "drug_name": "topotecan 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "636045", "drug_name": "hydrochlorothiazide 25 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "636042", "drug_name": "hydrochlorothiazide 12.5 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "630208", "drug_name": "albuterol 0.83 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "628958", "drug_name": "potassium chloride 10 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "628953", "drug_name": "potassium chloride 10 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "617995", "drug_name": "12 HR amoxicillin 1000 MG / clavulanate 62.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "617993", "drug_name": "amoxicillin 120 MG/ML / clavulanate 8.58 MG/ML Oral Suspension", "plans": [ 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] }, { "rxnorm_id": "616749", "drug_name": "12 HR ranolazine 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "616705", "drug_name": "risperidone 4 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616698", "drug_name": "risperidone 3 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616578", "drug_name": "lubiprostone 0.024 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616487", "drug_name": "quetiapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616483", "drug_name": "quetiapine 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616289", "drug_name": "sunitinib 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616285", "drug_name": "sunitinib 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616279", "drug_name": "sunitinib 12.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616148", "drug_name": "emtricitabine 10 MG/ML Oral Solution [Emtriva]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "616018", "drug_name": "abatacept 250 MG Injection [Orencia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "615882", "drug_name": "mecasermin 10 MG/ML Injectable Solution [Increlex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "608328", "drug_name": "rasagiline 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "608143", "drug_name": "atomoxetine 80 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "608139", "drug_name": "atomoxetine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "607579", "drug_name": "entecavir 0.05 MG/ML Oral Solution [Baraclude]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "606730", "drug_name": "esomeprazole 40 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "606726", "drug_name": "esomeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "603378", "drug_name": "tipranavir 250 MG Oral Capsule [Aptivus]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "603208", "drug_name": "erlotinib 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "603206", "drug_name": "erlotinib 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "603203", "drug_name": "erlotinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "603103", "drug_name": "naproxen 375 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "602964", "drug_name": "aripiprazole 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "602912", "drug_name": "lenalidomide 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "602910", "drug_name": "lenalidomide 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "602393", "drug_name": "abacavir 600 MG / lamivudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "598025", "drug_name": "amoxicillin 250 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597852", "drug_name": "anagrelide 1 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597850", "drug_name": "anagrelide 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597823", "drug_name": "tobramycin 40 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597772", "drug_name": "deferasirox 500 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597770", "drug_name": "deferasirox 250 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597768", "drug_name": "deferasirox 125 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597747", "drug_name": "sorafenib 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "597730", "drug_name": "lopinavir 200 MG / ritonavir 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "596934", "drug_name": "duloxetine 60 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "596930", "drug_name": "duloxetine 30 MG Delayed Release Oral Capsule", 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2027 ] } ] }, { "rxnorm_id": "582926", "drug_name": "podofilox 5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "581531", "drug_name": "tigecycline 50 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "579148", "drug_name": "galantamine 12 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "578330", "drug_name": "candesartan cilexetil 32 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "578325", "drug_name": "candesartan cilexetil 16 MG / hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577961", "drug_name": "amphetamine aspartate 5 MG / amphetamine sulfate 5 MG / dextroamphetamine saccharate 5 MG / dextroamphetamine sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "577957", "drug_name": "amphetamine aspartate 3.75 MG / amphetamine sulfate 3.75 MG / dextroamphetamine saccharate 3.75 MG / dextroamphetamine sulfate 3.75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "577776", "drug_name": "candesartan cilexetil 16 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577348", "drug_name": "ramelteon 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "577324", "drug_name": "paricalcitol 0.004 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577317", "drug_name": "paricalcitol 0.002 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577315", "drug_name": "paricalcitol 0.001 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577237", "drug_name": "metronidazole 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577208", "drug_name": "omega-3 acid ethyl esters (USP) 1000 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577154", "drug_name": "megestrol acetate 125 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577127", "drug_name": "pregabalin 225 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "577057", "drug_name": "72 HR fentanyl 0.012 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "577033", "drug_name": "sildenafil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "562847", "drug_name": "betaine 1000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "562806", "drug_name": "pimecrolimus 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "562704", "drug_name": "ropinirole 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "562524", "drug_name": "12 HR acetazolamide 500 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "562508", "drug_name": "amoxicillin 875 MG / clavulanate 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "562266", "drug_name": "clindamycin 15 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "562251", "drug_name": "amoxicillin 250 MG / clavulanate 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "545835", "drug_name": "leuprolide acetate 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "545255", "drug_name": "loteprednol etabonate 5 MG/ML / tobramycin 3 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "545118", "drug_name": "levofloxacin 15 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "544455", "drug_name": "lactulose 667 MG/ML Oral Solution [Generlac]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "544452", "drug_name": "lactulose 667 MG/ML Oral Solution [Constulose]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "543546", "drug_name": "nystatin 100000 UNT/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "543460", "drug_name": "ammonium lactate 120 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "542370", "drug_name": "nelfinavir 625 MG Oral Tablet [Viracept]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "541892", "drug_name": "amphetamine aspartate 2.5 MG / amphetamine sulfate 2.5 MG / dextroamphetamine saccharate 2.5 MG / dextroamphetamine sulfate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "541878", "drug_name": "amphetamine aspartate 1.25 MG / amphetamine sulfate 1.25 MG / dextroamphetamine saccharate 1.25 MG / dextroamphetamine sulfate 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "541363", "drug_name": "amphetamine aspartate 7.5 MG / amphetamine sulfate 7.5 MG / dextroamphetamine saccharate 7.5 MG / dextroamphetamine sulfate 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "539789", "drug_name": "rifaximin 200 MG Oral Tablet [XIFAXAN]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "486515", "drug_name": "sodium chloride 0.154 MEQ/ML Irrigation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "486152", "drug_name": "24 HR nitroglycerin 0.4 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "486148", "drug_name": "24 HR nitroglycerin 0.2 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "486146", "drug_name": "24 HR nitroglycerin 0.6 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "485968", "drug_name": "olanzapine 10 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "485647", "drug_name": "fluocinonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485496", "drug_name": "aripiprazole 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485465", "drug_name": "eszopiclone 3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485442", "drug_name": "eszopiclone 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485440", "drug_name": "eszopiclone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485436", "drug_name": "entecavir 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485434", "drug_name": "entecavir 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485032", "drug_name": "tiotropium 0.018 MG Inhalation Powder", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "485023", "drug_name": "mycophenolic acid 360 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "485020", "drug_name": "mycophenolic acid 180 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "483450", "drug_name": "pregabalin 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483448", "drug_name": "pregabalin 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483446", "drug_name": "pregabalin 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483444", "drug_name": "pregabalin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483442", "drug_name": "pregabalin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483440", "drug_name": "pregabalin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483438", "drug_name": "pregabalin 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "483090", "drug_name": "carbidopa 10 MG / levodopa 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477562", "drug_name": "fenofibrate 48 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477560", "drug_name": "fenofibrate 145 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477391", "drug_name": "levofloxacin 25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477372", "drug_name": "solifenacin succinate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477367", "drug_name": "solifenacin succinate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477234", "drug_name": "tinidazole 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "477130", "drug_name": "hydrochlorothiazide 25 MG / telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476809", "drug_name": "mirtazapine 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476576", "drug_name": "cefdinir 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476556", "drug_name": "emtricitabine 200 MG / tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "476515", "drug_name": "carbidopa 25 MG / levodopa 250 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476399", "drug_name": "carbidopa 25 MG / levodopa 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476362", "drug_name": "mesalamine 500 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "476351", "drug_name": "ezetimibe 10 MG / simvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476350", "drug_name": "ezetimibe 10 MG / simvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476349", "drug_name": "ezetimibe 10 MG / simvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476345", "drug_name": "ezetimibe 10 MG / simvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "476179", "drug_name": "clozapine 25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "476177", "drug_name": "clozapine 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "465355", "drug_name": "voriconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "432402", "drug_name": "cinacalcet 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "432401", "drug_name": "cinacalcet 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "432400", "drug_name": "cinacalcet 90 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "430902", "drug_name": "baclofen 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "430551", "drug_name": "benznidazole 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "429503", "drug_name": "hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "429212", "drug_name": "clozapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "427163", "drug_name": "nitazoxanide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "409823", "drug_name": "cefixime 400 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404657", "drug_name": "168 HR estradiol 0.0025 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404656", "drug_name": "168 HR estradiol 0.00156 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404459", "drug_name": "pegvisomant 20 MG Injection [Somavert]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404458", "drug_name": "pegvisomant 15 MG Injection [Somavert]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404457", "drug_name": "pegvisomant 10 MG Injection [Somavert]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404449", "drug_name": "thalidomide 100 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "404065", "drug_name": "isotretinoin 40 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404064", "drug_name": "isotretinoin 40 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404062", "drug_name": "isotretinoin 20 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404061", "drug_name": "isotretinoin 20 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404059", "drug_name": "isotretinoin 10 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404058", "drug_name": "isotretinoin 10 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403975", "drug_name": "alosetron 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403967", "drug_name": "zonisamide 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403966", "drug_name": "zonisamide 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403957", "drug_name": "tadalafil 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403930", "drug_name": "isotretinoin 30 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403923", "drug_name": "168 HR estradiol 0.0025 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403922", "drug_name": "168 HR estradiol 0.00156 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403920", "drug_name": "daptomycin 500 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403908", "drug_name": "ciprofloxacin 3 MG/ML / dexamethasone 1 MG/ML Otic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403888", "drug_name": "Microencapsulated potassium chloride 15 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403884", "drug_name": "levetiracetam 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403879", "drug_name": "imatinib 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403878", "drug_name": "imatinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403875", "drug_name": "emtricitabine 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403855", "drug_name": "hydrochlorothiazide 25 MG / olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403854", "drug_name": "hydrochlorothiazide 12.5 MG / olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403853", "drug_name": "hydrochlorothiazide 12.5 MG / olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403849", "drug_name": "estrogens, conjugated (USP) 0.45 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403825", "drug_name": "risperidone 0.5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403818", "drug_name": "moxifloxacin 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "403811", "drug_name": "aprepitant 125 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "403810", "drug_name": "aprepitant 80 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402698", "drug_name": "24 HR felodipine 2.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402696", "drug_name": "24 HR felodipine 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402695", "drug_name": "24 HR felodipine 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402506", "drug_name": "12 HR carbamazepine 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402505", "drug_name": "12 HR carbamazepine 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402252", "drug_name": "168 HR estradiol 0.00188 MG/HR / levonorgestrel 0.000625 MG/HR Transdermal System [Climara Pro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402247", "drug_name": "atazanavir 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402246", "drug_name": "atazanavir 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402131", "drug_name": "aripiprazole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402109", "drug_name": "fosamprenavir 700 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402092", "drug_name": "cyclosporine 0.5 MG/ML Ophthalmic Suspension [Restasis]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402012", "drug_name": "risperidone 50 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "402011", "drug_name": "risperidone 37.5 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402010", "drug_name": "risperidone 25 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "401954", "drug_name": "risperidone 2 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", 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"step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "360110", "drug_name": "sirolimus 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "359385", "drug_name": "24 HR clarithromycin 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "359296", "drug_name": "calcium acetate 667 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "358371", "drug_name": "clotrimazole 10 MG/ML Topical Spray", "plans": [ { "plan_id_type": "PLAN-ID", 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"years": [ 2027 ] } ] }, { "rxnorm_id": "351859", "drug_name": "insulin, regular, human 500 UNT/ML Injectable Solution [Humulin R]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351285", "drug_name": "escitalopram 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351267", "drug_name": "buprenorphine 8 MG / naloxone 2 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351266", "drug_name": "buprenorphine 2 MG / naloxone 0.5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351265", "drug_name": "buprenorphine 8 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351264", "drug_name": "buprenorphine 2 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351257", "drug_name": "eplerenone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351256", "drug_name": "eplerenone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351250", "drug_name": "escitalopram 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351249", "drug_name": "escitalopram 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351246", "drug_name": "montelukast 4 MG Oral Granules", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351223", "drug_name": "ziprasidone 20 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351209", "drug_name": "voriconazole 200 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351175", "drug_name": "nitisinone 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351174", "drug_name": "nitisinone 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351173", "drug_name": "nitisinone 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351172", "drug_name": "dutasteride 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351156", "drug_name": "250 ML moxifloxacin 1.6 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351155", "drug_name": "urea 400 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351137", "drug_name": "albuterol 0.21 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351136", "drug_name": "albuterol 0.417 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351133", "drug_name": "fenofibrate 54 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351109", "drug_name": "budesonide 0.25 MG/ML Inhalation Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351108", "drug_name": "olanzapine 20 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351107", "drug_name": "olanzapine 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349595", "drug_name": "atomoxetine 60 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349594", "drug_name": "atomoxetine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349593", "drug_name": "atomoxetine 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349592", "drug_name": "atomoxetine 18 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349591", "drug_name": "atomoxetine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349556", "drug_name": "ezetimibe 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349553", "drug_name": "aripiprazole 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349547", "drug_name": "aripiprazole 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349545", "drug_name": "aripiprazole 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349514", "drug_name": "celecoxib 400 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349491", "drug_name": "lamivudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349490", "drug_name": "aripiprazole 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349483", "drug_name": "valsartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349482", "drug_name": "sodium oxybate 500 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349477", "drug_name": "efavirenz 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349472", "drug_name": "gefitinib 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349435", "drug_name": "voriconazole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349434", "drug_name": "voriconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349405", "drug_name": "olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349401", "drug_name": "olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349373", "drug_name": "olmesartan medoxomil 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349353", "drug_name": "hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349351", "drug_name": "desonide 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349332", "drug_name": "escitalopram 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349287", "drug_name": "fenofibrate 160 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349251", "drug_name": "tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "349208", "drug_name": "sirolimus 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "349201", "drug_name": "valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "317094", "drug_name": "entacapone 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "315223", "drug_name": "sumatriptan 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "315183", "drug_name": "potassium chloride 8 MEQ Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "315134", "drug_name": "levocarnitine 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "315107", "drug_name": "24 HR glipizide 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "315090", "drug_name": "erythromycin 333 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314286", "drug_name": "ziprasidone 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "314285", "drug_name": "zonisamide 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"years": [ 2027 ] } ] }, { "rxnorm_id": "314234", "drug_name": "sucralfate 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314231", "drug_name": "simvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314230", "drug_name": "sirolimus 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314227", "drug_name": "sumatriptan 20 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, 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"FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "314208", "drug_name": "ropinirole 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314203", "drug_name": "quinapril 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314200", "drug_name": "pantoprazole 40 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "314182", "drug_name": "potassium chloride 2.67 MEQ/ML Oral Solution", 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314106", "drug_name": "metronidazole 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314080", "drug_name": "levofloxacin 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314078", "drug_name": "loxapine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314077", "drug_name": "lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314035", "drug_name": "haloperidol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314034", "drug_name": "haloperidol 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314006", "drug_name": "24 HR glipizide 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313996", "drug_name": "gentamicin 40 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313989", "drug_name": "fluoxetine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313988", "drug_name": "furosemide 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313979", "drug_name": "fludrocortisone acetate 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313941", "drug_name": "ciclopirox 0.0077 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313921", "drug_name": "calcipotriene 0.05 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313920", "drug_name": "cefazolin 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313919", "drug_name": "salmon calcitonin 200 UNT/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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[ 2027 ] } ] }, { "rxnorm_id": "313585", "drug_name": "24 HR venlafaxine 75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313584", "drug_name": "venlafaxine 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313583", "drug_name": "24 HR venlafaxine 37.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313582", "drug_name": "venlafaxine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313472", "drug_name": "trientine hydrochloride 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313447", "drug_name": "tranylcypromine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313428", "drug_name": "toremifene 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313416", "drug_name": "tobramycin 10 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313415", "drug_name": "tobramycin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313413", "drug_name": "tizanidine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313412", "drug_name": "tizanidine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313366", "drug_name": "thiothixene 5 MG Oral Capsule", "plans": [ { "plan_id_type": 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Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313291", "drug_name": "theophylline 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313227", "drug_name": "terconazole 8 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313226", "drug_name": "terconazole 4 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313222", "drug_name": "terbinafine 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313219", "drug_name": "terazosin 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313217", "drug_name": "terazosin 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313215", "drug_name": "terazosin 1 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313200", "drug_name": "tazarotene 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313195", "drug_name": "tamoxifen 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313190", "drug_name": "tacrolimus 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313189", "drug_name": "tacrolimus 0.0003 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313165", "drug_name": "0.5 ML sumatriptan 12 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313161", "drug_name": "sumatriptan 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313160", "drug_name": "sumatriptan 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313159", "drug_name": "sumatriptan 5 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313142", "drug_name": "sulfasalazine 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313134", "drug_name": "sulfamethoxazole 40 MG/ML / trimethoprim 8 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313115", "drug_name": "streptomycin 1000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313096", "drug_name": "spironolactone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313072", "drug_name": "sodium polystyrene sulfonate 250 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312962", "drug_name": "simvastatin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312961", "drug_name": "simvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312941", "drug_name": "sertraline 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312940", "drug_name": "sertraline 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312938", "drug_name": "sertraline 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312849", "drug_name": "ropinirole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312847", "drug_name": "ropinirole 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312846", "drug_name": "ropinirole 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312845", "drug_name": "ropinirole 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312840", "drug_name": "rizatriptan 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312839", "drug_name": "rizatriptan 5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312837", "drug_name": "rizatriptan 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312836", "drug_name": "rivastigmine 6 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312835", 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] } ] }, { "rxnorm_id": "312829", "drug_name": "risperidone 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312828", "drug_name": "risperidone 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312821", "drug_name": "rifampin 600 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312750", "drug_name": "quinapril 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312749", "drug_name": "quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312748", "drug_name": "quinapril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312745", "drug_name": "quetiapine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312744", "drug_name": "quetiapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312615", "drug_name": "prednisone 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312614", "drug_name": "prednisolone 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312594", "drug_name": "prazosin 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312593", "drug_name": "prazosin 1 MG Oral Capsule", 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"years": [ 2027 ] } ] }, { "rxnorm_id": "312504", "drug_name": "potassium chloride 10 MEQ Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312447", "drug_name": "piperacillin 200 MG/ML / tazobactam 25 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312441", "drug_name": "pioglitazone 45 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312440", "drug_name": "pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312439", "drug_name": "pimozide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312362", "drug_name": "phenobarbital 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312357", "drug_name": "phenobarbital 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312347", "drug_name": "phenelzine 15 MG Oral Tablet", "plans": [ { 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"rxnorm_id": "312137", "drug_name": "oxcarbazepine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312136", "drug_name": "oxcarbazepine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312132", "drug_name": "oxaprozin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312122", "drug_name": "oseltamivir 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312087", "drug_name": "ondansetron 8 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312086", "drug_name": "ondansetron 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312085", "drug_name": "ondansetron 0.8 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312079", "drug_name": "olanzapine 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312078", "drug_name": "olanzapine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312077", "drug_name": "olanzapine 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312076", "drug_name": "olanzapine 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312075", "drug_name": "ofloxacin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312071", "drug_name": "octreotide 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312070", "drug_name": "1 ML octreotide 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312069", "drug_name": "1 ML octreotide 0.1 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312068", "drug_name": "1 ML octreotide 0.05 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312059", "drug_name": "nystatin 500000 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312055", "drug_name": "nystatin 100000 UNT/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312036", "drug_name": "nortriptyline 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312025", "drug_name": "nizatidine 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311995", "drug_name": "nitrofurantoin, macrocrystals 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311982", "drug_name": "nilutamide 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311943", "drug_name": "nevirapine 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311919", "drug_name": "nateglinide 120 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311918", "drug_name": "naratriptan 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311915", "drug_name": "naproxen 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311893", "drug_name": "nabumetone 750 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311892", "drug_name": "nabumetone 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311880", "drug_name": "mycophenolate mofetil 200 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311877", "drug_name": "mupirocin 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311787", "drug_name": "moxifloxacin 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311759", "drug_name": "montelukast 4 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311753", "drug_name": "mometasone furoate 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311727", "drug_name": "misoprostol 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311726", "drug_name": "mirtazapine 45 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311725", "drug_name": "mirtazapine 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311704", "drug_name": "mifepristone 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311683", "drug_name": "100 ML metronidazole 5 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": 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"AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311668", "drug_name": "metoclopramide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311666", "drug_name": "metoclopramide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311625", "drug_name": "methotrexate 1000 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311486", "drug_name": "meloxicam 7.5 MG Oral Tablet", 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"years": [ 2027 ] } ] }, { "rxnorm_id": "311345", "drug_name": "linezolid 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311296", "drug_name": "levofloxacin 750 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311290", "drug_name": "levetiracetam 750 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311289", "drug_name": "levetiracetam 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311288", "drug_name": "levetiracetam 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311286", "drug_name": "levalbuterol 0.21 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311277", "drug_name": "lansoprazole 30 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311265", "drug_name": "lamotrigine 5 MG Tablet for Oral Suspension", "plans": [ { 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"step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311036", "drug_name": "insulin, regular, human 100 UNT/ML Injectable Solution [Humulin R]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311033", "drug_name": "insulin, regular, human 100 UNT/ML Injectable Solution [Novolin R]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311027", "drug_name": "insulin isophane, human 100 UNT/ML Injectable Suspension [Novolin N]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311026", "drug_name": "insulin isophane, human 100 UNT/ML Injectable Suspension [Humulin N]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310994", "drug_name": "infliximab 100 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310992", "drug_name": "indomethacin 75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310982", "drug_name": "imiquimod 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310891", "drug_name": "hydrocortisone 25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310891", "drug_name": "hydrocortisone 25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310878", "drug_name": "hydrocortisone 1.67 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310818", "drug_name": "hydrochlorothiazide 50 MG / triamterene 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310812", "drug_name": "hydrochlorothiazide 25 MG / triamterene 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310809", "drug_name": "hydrochlorothiazide 25 MG / quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310798", "drug_name": "hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310797", "drug_name": "hydrochlorothiazide 12.5 MG / quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310796", "drug_name": "hydrochlorothiazide 12.5 MG / quinapril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310793", "drug_name": "hydrochlorothiazide 12.5 MG / irbesartan 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310792", "drug_name": "hydrochlorothiazide 12.5 MG / irbesartan 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310687", "drug_name": "hydrocortisone 10 MG/ML / neomycin 3.5 MG/ML / polymyxin B 10000 UNT/ML Otic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310672", "drug_name": "haloperidol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310671", "drug_name": "haloperidol 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310670", "drug_name": "haloperidol 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310600", "drug_name": "griseofulvin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310594", "drug_name": "gramicidin 0.025 MG/ML / neomycin 1.75 MG/ML / polymyxin B 10000 UNT/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310537", "drug_name": "glyburide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310534", "drug_name": "glyburide 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310497", "drug_name": "glucagon (rDNA) 1 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310490", "drug_name": "glipizide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310489", "drug_name": "24 HR glipizide 2.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310488", "drug_name": "glipizide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310467", "drug_name": "gentamicin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310465", "drug_name": "gentamicin 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310459", "drug_name": "gemfibrozil 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310442", "drug_name": "ganciclovir 500 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310437", "drug_name": "galantamine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310436", "drug_name": "galantamine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310434", "drug_name": "gabapentin 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310433", "drug_name": "gabapentin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310432", "drug_name": "gabapentin 400 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310431", "drug_name": "gabapentin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310430", "drug_name": "gabapentin 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310429", "drug_name": "furosemide 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310405", "drug_name": "fluvastatin 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310404", "drug_name": "fluvastatin 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310386", "drug_name": "fluoxetine 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310385", "drug_name": "fluoxetine 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310384", "drug_name": "fluoxetine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310380", "drug_name": "fluorouracil 50 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310379", "drug_name": "fluorouracil 20 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310377", "drug_name": "fluorometholone 1 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310364", "drug_name": "fluocinonide 0.5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310362", "drug_name": "fluocinonide 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310353", "drug_name": "fluconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310352", "drug_name": "fluconazole 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310346", "drug_name": "finasteride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310289", "drug_name": "fenofibrate 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310288", "drug_name": "fenofibrate 134 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310285", "drug_name": "felbamate 120 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310274", "drug_name": "famotidine 8 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310273", "drug_name": "famotidine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310261", "drug_name": "exemestane 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310197", "drug_name": "estrogens, conjugated (USP) 0.625 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310181", "drug_name": "168 HR estradiol 0.00417 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310178", "drug_name": "168 HR estradiol 0.00312 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310174", "drug_name": "168 HR estradiol 0.00208 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310170", "drug_name": "168 HR estradiol 0.00104 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310169", "drug_name": "estradiol 0.1 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310157", "drug_name": "erythromycin 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310155", "drug_name": "erythromycin 250 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310152", "drug_name": "erythromycin 0.02 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310149", "drug_name": "erythromycin 0.005 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310027", "drug_name": "doxycycline hyclate 100 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310015", "drug_name": "dorzolamide 20 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310005", "drug_name": "dofetilide 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310004", "drug_name": "dofetilide 0.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310003", "drug_name": "dofetilide 0.125 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309960", "drug_name": "disopyramide 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309958", "drug_name": "disopyramide 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309844", "drug_name": "diazepam 5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309843", "drug_name": "diazepam 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309686", "drug_name": "dexamethasone 0.1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309683", "drug_name": "dexamethasone 1 MG/ML / tobramycin 3 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309680", "drug_name": "dexamethasone 1 MG/ML / neomycin 3.5 MG/ML / polymyxin B 10000 UNT/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309679", "drug_name": "dexamethasone 0.001 MG/MG / neomycin 0.0035 MG/MG / polymyxin B 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309374", "drug_name": "clozapine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309371", "drug_name": "clotrimazole 10 MG Oral Lozenge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309370", "drug_name": "clotrimazole 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309367", "drug_name": "clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309362", "drug_name": "clopidogrel 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309337", "drug_name": "clindamycin 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309333", "drug_name": "clindamycin 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309329", "drug_name": "clindamycin 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309322", "drug_name": "clarithromycin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309314", "drug_name": "citalopram 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309313", "drug_name": "citalopram 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309311", "drug_name": "cisplatin 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309309", "drug_name": "ciprofloxacin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309307", "drug_name": "ciprofloxacin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309291", "drug_name": "ciclopirox 80 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309290", "drug_name": "ciclopirox 7.7 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309289", "drug_name": "ciclopirox 7.7 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309114", "drug_name": "cephalexin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309113", "drug_name": "cephalexin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309112", "drug_name": "cephalexin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309110", "drug_name": "cephalexin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309098", "drug_name": "cefuroxime 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309097", "drug_name": "cefuroxime 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309092", "drug_name": "ceftriaxone 250 MG Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309090", "drug_name": "ceftriaxone 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309081", "drug_name": "cefprozil 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309080", "drug_name": "cefprozil 25 MG/ML Oral Suspension", "plans": [ { 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false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309048", "drug_name": "cefadroxil 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309045", "drug_name": "cefaclor 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308989", "drug_name": "carbidopa 50 MG / levodopa 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308988", "drug_name": "carbidopa 25 MG / levodopa 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308979", "drug_name": "carbamazepine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308976", "drug_name": "carbamazepine 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308973", "drug_name": "carbamazepine 100 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308964", "drug_name": "captopril 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308963", "drug_name": "captopril 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308962", "drug_name": "captopril 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308868", "drug_name": "calcitriol 0.0005 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308867", "drug_name": "calcitriol 0.00025 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308865", "drug_name": "calcipotriene 0.05 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308805", "drug_name": "brinzolamide 10 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308725", "drug_name": "bexarotene 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308724", "drug_name": "bexarotene 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308720", "drug_name": "betaxolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308714", "drug_name": "betamethasone 0.5 MG/ML / clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308511", "drug_name": "bacitracin 0.5 UNT/MG / polymyxin B 10 UNT/MG Ophthalmic Ointment", 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308459", "drug_name": "azithromycin 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308429", "drug_name": "atovaquone 150 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308212", "drug_name": "ampicillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308194", "drug_name": "amoxicillin 875 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308192", "drug_name": "amoxicillin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308191", "drug_name": "amoxicillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308189", "drug_name": "amoxicillin 80 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308182", "drug_name": "amoxicillin 250 MG Oral Capsule", "plans": [ { 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"alprazolam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308047", "drug_name": "alprazolam 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "307730", "drug_name": "acyclovir 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307707", "drug_name": "acetic acid 2.5 MG/ML Irrigation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "285018", "drug_name": "insulin glargine 100 UNT/ML Injectable Solution [Lantus]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284254", "drug_name": "prochlorperazine 25 MG Rectal Suppository [Compro]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284245", "drug_name": "famotidine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284215", "drug_name": "clindamycin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284008", "drug_name": "travoprost 0.04 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283858", "drug_name": "ropinirole 3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283672", "drug_name": "citalopram 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283639", "drug_name": "olanzapine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283536", "drug_name": "oxcarbazepine 60 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283535", "drug_name": "doxycycline hyclate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283523", "drug_name": "gabapentin 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283485", "drug_name": "mirtazapine 45 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283407", "drug_name": "mirtazapine 30 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283406", "drug_name": "mirtazapine 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283317", "drug_name": "hydrochlorothiazide 12.5 MG / telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283316", "drug_name": "hydrochlorothiazide 12.5 MG / telmisartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283077", "drug_name": "prednisolone 3 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "282755", "drug_name": "telmisartan 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "282486", "drug_name": "bumetanide 0.25 MG/ML Injectable Solution", 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"260376", "drug_name": "terazosin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "260260", "drug_name": "carbidopa 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "260243", "drug_name": "progesterone 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "260218", "drug_name": "modafinil 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, 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"FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "252559", "drug_name": "budesonide 0.5 MG/ML Inhalation Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "252413", "drug_name": "topiramate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "251872", "drug_name": "pantoprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "251322", "drug_name": "ethosuximide 50 MG/ML Oral Solution", 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"step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "246172", "drug_name": "clobazam 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "245314", "drug_name": "albuterol 5 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "245136", "drug_name": "72 HR fentanyl 0.1 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "245135", "drug_name": "72 HR fentanyl 0.05 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", 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"years": [ 2027 ] } ] }, { "rxnorm_id": "242946", "drug_name": "nitroglycerin 0.02 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "242892", "drug_name": "84 HR estradiol 0.00417 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242891", "drug_name": "84 HR estradiol 0.00208 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242831", "drug_name": "griseofulvin 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "242800", "drug_name": "ceftazidime 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "242680", "drug_name": "abacavir 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242679", "drug_name": "abacavir 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242671", "drug_name": "rifapentine 150 MG Oral Tablet", "plans": [ { 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"montelukast 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242333", "drug_name": "168 HR estradiol 0.00104 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "242120", "drug_name": "insulin lispro 100 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "241946", "drug_name": "84 HR estradiol 0.00156 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "241834", "drug_name": "cyclosporine, modified 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "241527", "drug_name": "168 HR estradiol 0.00312 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "240984", "drug_name": "ampicillin 100 MG/ML / sulbactam 50 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "240741", "drug_name": "clarithromycin 25 MG/ML Oral Suspension", "plans": [ { 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238920", "drug_name": "betamethasone 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238600", "drug_name": "selenium sulfide 25 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238154", "drug_name": "acetaminophen 325 MG / butalbital 50 MG / caffeine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238151", "drug_name": "mesalamine 66.7 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "238151", "drug_name": "mesalamine 66.7 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238004", "drug_name": "168 HR estradiol 0.00417 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "238003", "drug_name": "168 HR estradiol 0.00208 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "226597", "drug_name": "estradiol 0.0006 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "226552", "drug_name": "72 HR scopolamine 0.0139 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "226343", "drug_name": "dexamethasone phosphate 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213502", "drug_name": "alitretinoin 0.001 MG/MG Topical Gel [Panretin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "213475", "drug_name": "1 ML epoetin alfa 40000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213442", "drug_name": "insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Novolin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213360", "drug_name": "thalidomide 50 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213337", "drug_name": 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false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212219", "drug_name": "epoetin alfa 20000 UNT/ML Injectable Solution [Procrit]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212118", "drug_name": "nelfinavir 250 MG Oral Tablet [Viracept]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "211140", "drug_name": "pentosan polysulfate 100 MG Oral Capsule [Elmiron]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "209789", "drug_name": "cysteamine 50 MG Oral Capsule [Cystagon]", "plans": [ { 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"quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "208083", "drug_name": "sargramostim 0.25 MG/ML Injectable Solution [Leukine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "207949", "drug_name": "succimer 100 MG Oral Capsule [Chemet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "207588", "drug_name": "procarbazine 50 MG Oral Capsule [Matulane]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "207373", "drug_name": "mitotane 500 MG Oral Tablet [Lysodren]", "plans": [ { "plan_id_type": "PLAN-ID", 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false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206842", "drug_name": "isosorbide dinitrate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206798", "drug_name": "mesalamine 66.7 MG/ML Enema [Rowasa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206423", "drug_name": "ceftazidime 200 MG/ML Injectable Solution [Tazicef]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206347", "drug_name": "hydrocortisone 10 MG/ML Topical Cream [Ala-Cort]", "plans": [ { "plan_id_type": 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"prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "205326", "drug_name": "lisinopril 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205324", "drug_name": "modafinil 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "205323", "drug_name": "celecoxib 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "205322", "drug_name": "celecoxib 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "205316", "drug_name": "topiramate 15 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205315", "drug_name": "topiramate 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205305", "drug_name": "telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205304", "drug_name": "telmisartan 40 MG Oral Tablet", "plans": [ { 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"isoniazid 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204423", "drug_name": "hydrocortisone 10 MG/ML / neomycin 3.5 MG/ML / polymyxin B 10000 UNT/ML Otic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204416", "drug_name": "haloperidol 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204135", "drug_name": "desonide 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "204119", "drug_name": "malathion 5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "203105", "drug_name": "hydrocortisone 0.01 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "203088", "drug_name": "ketoconazole 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "201708", "drug_name": "isocarboxazid 10 MG Oral Tablet [Marplan]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200371", "drug_name": "citalopram 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200346", "drug_name": "cefdinir 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200345", "drug_name": "simvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200329", "drug_name": "omeprazole 40 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200311", "drug_name": "fenofibrate 67 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200285", "drug_name": "hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200284", "drug_name": "hydrochlorothiazide 12.5 MG / valsartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200258", "drug_name": "repaglinide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200257", "drug_name": "repaglinide 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200256", "drug_name": "repaglinide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200224", "drug_name": "montelukast 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200194", "drug_name": "zolmitriptan 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200193", "drug_name": "zolmitriptan 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200133", "drug_name": "12 HR carbamazepine 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200132", "drug_name": "acarbose 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200131", "drug_name": "12 HR carbamazepine 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200096", "drug_name": "irbesartan 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200095", "drug_name": "irbesartan 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200094", "drug_name": "irbesartan 75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200082", "drug_name": "lamivudine 150 MG / zidovudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200064", "drug_name": "letrozole 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200060", "drug_name": "mycophenolate mofetil 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200034", "drug_name": "olanzapine 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "200033", "drug_name": "carvedilol 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200032", "drug_name": "carvedilol 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200031", "drug_name": "carvedilol 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199998", "drug_name": "ivermectin 6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199903", "drug_name": "hydrochlorothiazide 12.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199890", "drug_name": "topiramate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199889", "drug_name": "topiramate 100 MG Oral Tablet", "plans": [ { 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"cabergoline 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199690", "drug_name": "acitretin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199689", "drug_name": "acitretin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199672", "drug_name": "albendazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199663", "drug_name": "zidovudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199655", "drug_name": "zafirlukast 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199592", "drug_name": "tetrabenazine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199521", "drug_name": "vigabatrin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199519", "drug_name": "tinidazole 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199450", "drug_name": "clobazam 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199422", "drug_name": "nevirapine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199390", "drug_name": "etodolac 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199353", "drug_name": "trandolapril 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199352", "drug_name": "trandolapril 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199351", "drug_name": "trandolapril 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199247", "drug_name": "glimepiride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199246", "drug_name": "glimepiride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199245", "drug_name": "glimepiride 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199224", "drug_name": "anastrozole 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199206", "drug_name": "riluzole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199193", "drug_name": "famciclovir 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199192", "drug_name": "famciclovir 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199168", "drug_name": "phenobarbital 64.8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", 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"rxnorm_id": "198428", "drug_name": "lamotrigine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198427", "drug_name": "lamotrigine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198382", "drug_name": "famciclovir 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198378", "drug_name": "tacrolimus 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198377", "drug_name": "tacrolimus 1 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198373", "drug_name": "calcipotriene 0.00005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198372", "drug_name": "torsemide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198371", "drug_name": "torsemide 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198370", "drug_name": "torsemide 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198369", "drug_name": "torsemide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198365", "drug_name": "prochlorperazine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198359", "drug_name": "felbamate 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198358", "drug_name": "felbamate 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198352", "drug_name": "zidovudine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198335", "drug_name": "sulfamethoxazole 800 MG / trimethoprim 160 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198334", "drug_name": "sulfamethoxazole 400 MG / trimethoprim 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198332", "drug_name": "trimethoprim 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198325", "drug_name": "trifluoperazine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198324", "drug_name": "trifluoperazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198323", "drug_name": "trifluoperazine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198322", "drug_name": "trifluoperazine 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198316", "drug_name": "hydrochlorothiazide 25 MG / triamterene 37.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198313", "drug_name": "triamterene 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198312", "drug_name": "triamterene 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198286", "drug_name": "timolol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198285", "drug_name": "timolol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198284", "drug_name": "timolol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198275", "drug_name": "thioridazine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198274", "drug_name": "thioridazine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198270", "drug_name": "thioridazine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198252", "drug_name": "tetracycline hydrochloride 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198250", "drug_name": "tetracycline hydrochloride 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198242", "drug_name": "temazepam 30 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198241", "drug_name": "temazepam 15 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198240", "drug_name": "tamoxifen 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198239", "drug_name": "sulindac 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198238", "drug_name": "sulindac 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198232", "drug_name": "sulfasalazine 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198228", "drug_name": "sulfadiazine 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198224", "drug_name": "hydrochlorothiazide 25 MG / spironolactone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198223", "drug_name": "spironolactone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198222", "drug_name": "spironolactone 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198211", "drug_name": "simvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198202", "drug_name": "rifampin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198201", "drug_name": "rifampin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198200", "drug_name": "rifabutin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198189", "drug_name": "ramipril 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198188", "drug_name": "ramipril 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198182", "drug_name": "pyrimethamine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198181", "drug_name": "pyrazinamide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198175", "drug_name": "propylthiouracil 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198159", "drug_name": "prochlorperazine 25 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198153", "drug_name": "colchicine 0.5 MG / probenecid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198152", "drug_name": "probenecid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198150", "drug_name": "primidone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198148", "drug_name": "prednisone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198146", "drug_name": "prednisone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198145", "drug_name": "prednisone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198144", "drug_name": "prednisone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198141", "drug_name": "prazosin 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198140", "drug_name": "praziquantel 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198116", "drug_name": "potassium chloride 20 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198108", "drug_name": "piroxicam 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198107", "drug_name": "piroxicam 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198105", "drug_name": "pindolol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198104", "drug_name": "pindolol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198103", "drug_name": "pimozide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198089", "drug_name": "phenobarbital 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198086", "drug_name": "phenobarbital 16.2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198083", "drug_name": "phenobarbital 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198078", "drug_name": "perphenazine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198077", "drug_name": "perphenazine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198076", "drug_name": "perphenazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198075", "drug_name": "perphenazine 16 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198071", "drug_name": "penicillamine 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198052", "drug_name": "ondansetron 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198051", "drug_name": "omeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198047", "drug_name": "nortriptyline 75 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198046", "drug_name": "nortriptyline 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198045", "drug_name": "nortriptyline 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198041", "drug_name": "nizatidine 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198040", "drug_name": "nitroglycerin 0.6 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198039", "drug_name": "nitroglycerin 0.4 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198038", "drug_name": "nitroglycerin 0.3 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198037", "drug_name": "nimodipine 30 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198036", "drug_name": "24 HR nifedipine 90 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198035", "drug_name": "24 HR nifedipine 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198034", "drug_name": "24 HR nifedipine 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198014", "drug_name": "naproxen 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198013", "drug_name": "naproxen 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198012", "drug_name": "naproxen 375 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198008", "drug_name": "nadolol 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198007", "drug_name": "nadolol 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198006", "drug_name": "nadolol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197987", "drug_name": "minoxidil 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197986", "drug_name": "minoxidil 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197985", "drug_name": "minocycline 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197984", "drug_name": "minocycline 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197980", "drug_name": "metyrosine 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197979", "drug_name": "metolazone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197978", "drug_name": "metolazone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197973", "drug_name": "methylprednisolone 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197971", "drug_name": "methylprednisolone 32 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197958", "drug_name": "methyldopa 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197956", "drug_name": "methyldopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197949", "drug_name": "methsuximide 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197944", "drug_name": "methocarbamol 750 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197943", "drug_name": "methocarbamol 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197942", "drug_name": "methimazole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197941", "drug_name": "methimazole 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197931", "drug_name": "mercaptopurine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197905", "drug_name": "lovastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197904", "drug_name": "lovastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197903", "drug_name": "lovastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197902", "drug_name": "lorazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197901", "drug_name": "lorazepam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197900", "drug_name": "lorazepam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197896", "drug_name": "lomustine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197895", "drug_name": "lomustine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197894", "drug_name": "lomustine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197893", "drug_name": "lithium carbonate 600 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197892", "drug_name": "lithium carbonate 450 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197891", "drug_name": "lithium carbonate 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197890", "drug_name": "lithium carbonate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197889", "drug_name": "lithium carbonate 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197887", "drug_name": "hydrochlorothiazide 25 MG / lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197886", "drug_name": "hydrochlorothiazide 12.5 MG / lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197885", "drug_name": "hydrochlorothiazide 12.5 MG / lisinopril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197884", "drug_name": "lisinopril 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197877", "drug_name": "lidocaine 25 MG/ML / prilocaine 25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197863", "drug_name": "leucovorin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197862", "drug_name": "leucovorin 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197861", "drug_name": "leucovorin 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197860", "drug_name": "leucovorin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197853", "drug_name": "ketoconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197845", "drug_name": "isotretinoin 40 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197844", "drug_name": "isotretinoin 20 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197843", "drug_name": "isotretinoin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197839", "drug_name": "isosorbide dinitrate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197832", "drug_name": "isoniazid 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197818", "drug_name": "indomethacin 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197817", "drug_name": "indomethacin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197816", "drug_name": "indapamide 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197815", "drug_name": "indapamide 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197807", "drug_name": "ibuprofen 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197806", "drug_name": "ibuprofen 600 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197805", "drug_name": "ibuprofen 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197803", "drug_name": "ibuprofen 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197797", "drug_name": "hydroxyurea 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197787", "drug_name": "hydrocortisone 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197785", "drug_name": "hydrocortisone 25 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197783", "drug_name": "hydrocortisone 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197782", "drug_name": "hydrocortisone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197770", "drug_name": "hydrochlorothiazide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197754", "drug_name": "haloperidol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197746", "drug_name": "guanfacine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197745", "drug_name": "guanfacine 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197739", "drug_name": "glycopyrrolate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197738", "drug_name": "glycopyrrolate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197737", "drug_name": "glyburide 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197735", "drug_name": "gentamicin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197732", "drug_name": "furosemide 80 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197731", "drug_name": "furosemide 8 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197730", "drug_name": "furosemide 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197724", "drug_name": "flurbiprofen 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197703", "drug_name": "flucytosine 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197702", "drug_name": "flucytosine 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197701", "drug_name": "fluconazole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197700", "drug_name": "fluconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197699", "drug_name": "fluconazole 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197698", "drug_name": "fluconazole 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197696", "drug_name": "72 HR fentanyl 0.075 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197686", "drug_name": "etodolac 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197685", "drug_name": "etodolac 300 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197684", "drug_name": "etodolac 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197682", "drug_name": "ethosuximide 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197662", "drug_name": "estrogens, conjugated (USP) 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197661", "drug_name": "estrogens, conjugated (USP) 0.9 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197660", "drug_name": "estrogens, conjugated (USP) 0.3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197659", "drug_name": "estradiol 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197658", "drug_name": "estradiol 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197657", "drug_name": "estradiol 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197636", "drug_name": "dronabinol 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197635", "drug_name": "dronabinol 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197634", "drug_name": "dronabinol 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197628", "drug_name": "doxazosin 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197627", "drug_name": "doxazosin 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197626", "drug_name": "doxazosin 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197625", "drug_name": "doxazosin 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197624", "drug_name": "disulfiram 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197623", "drug_name": "disulfiram 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197606", "drug_name": "digoxin 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197604", "drug_name": "digoxin 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197596", "drug_name": "dicloxacillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197595", "drug_name": "dicloxacillin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197593", "drug_name": "diazoxide 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197591", "drug_name": "diazepam 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197590", "drug_name": "diazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197589", "drug_name": "diazepam 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197583", "drug_name": "dexamethasone 6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197582", "drug_name": "dexamethasone 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197581", "drug_name": "dexamethasone 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197580", "drug_name": "dexamethasone 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197579", "drug_name": "dexamethasone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197577", "drug_name": "dexamethasone 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197575", "drug_name": "desoximetasone 0.0025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197574", "drug_name": "desoximetasone 2.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197558", "drug_name": "dapsone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197557", "drug_name": "dapsone 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197556", "drug_name": "danazol 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197555", "drug_name": "danazol 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197554", "drug_name": "danazol 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197553", "drug_name": "cyclosporine 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197551", "drug_name": "cycloserine 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197541", "drug_name": "colchicine 0.6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197536", "drug_name": "clozapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197535", "drug_name": "clozapine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197529", "drug_name": "clonazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197528", "drug_name": "clonazepam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197527", "drug_name": "clonazepam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197519", "drug_name": "clindamycin 10 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197518", "drug_name": "clindamycin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197517", "drug_name": "clarithromycin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197516", "drug_name": "clarithromycin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197512", "drug_name": "ciprofloxacin 750 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197511", "drug_name": "ciprofloxacin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197500", "drug_name": "chlorthalidone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197499", "drug_name": "chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197466", "drug_name": "clorazepate dipotassium 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197465", "drug_name": "clorazepate dipotassium 3.75 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197464", "drug_name": "clorazepate dipotassium 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197453", "drug_name": "cefprozil 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197452", "drug_name": "cefprozil 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197449", "drug_name": "cefaclor 500 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197448", "drug_name": "levocarnitine 330 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197445", "drug_name": "carbidopa 25 MG / levodopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197444", "drug_name": "carbidopa 25 MG / levodopa 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197443", "drug_name": "carbidopa 10 MG / levodopa 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197442", "drug_name": "carbamazepine 200 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197439", "drug_name": "captopril 50 MG / hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197438", "drug_name": "captopril 50 MG / hydrochlorothiazide 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197437", "drug_name": "captopril 25 MG / hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197436", "drug_name": "captopril 25 MG / hydrochlorothiazide 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197433", "drug_name": "calcium acetate 667 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197419", "drug_name": "bumetanide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197418", "drug_name": "bumetanide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197417", "drug_name": "bumetanide 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197412", "drug_name": "bromocriptine 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197411", "drug_name": "bromocriptine 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197409", "drug_name": "betamethasone 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197408", "drug_name": "betamethasone 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197407", "drug_name": "betamethasone 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197405", "drug_name": "betamethasone 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197392", "drug_name": "baclofen 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197391", "drug_name": "baclofen 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197388", "drug_name": "azathioprine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197383", "drug_name": "atenolol 50 MG / chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197382", "drug_name": "atenolol 100 MG / chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197381", "drug_name": "atenolol 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197380", "drug_name": "atenolol 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197379", "drug_name": "atenolol 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197366", "drug_name": "amoxapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197365", "drug_name": "amoxapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197364", "drug_name": "amoxapine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197363", "drug_name": "amoxapine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197362", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197361", "drug_name": "amlodipine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197322", "drug_name": "alprazolam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197321", "drug_name": "alprazolam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197320", "drug_name": "allopurinol 300 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197319", "drug_name": "allopurinol 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197313", "drug_name": "acyclovir 800 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197312", "drug_name": "acyclovir 0.05 MG/MG Topical 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"197304", "drug_name": "acetazolamide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197303", "drug_name": "acetazolamide 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153880", "drug_name": "deflazacort 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153823", "drug_name": "candesartan cilexetil 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153822", "drug_name": "candesartan cilexetil 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153098", "drug_name": "deflazacort 6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "152695", "drug_name": "meloxicam 15 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "151226", "drug_name": "topiramate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "151030", "drug_name": "mometasone furoate 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "151029", "drug_name": "mometasone furoate 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "142113", "drug_name": "mesna 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "142046", "drug_name": "metronidazole 0.0075 MG/MG Vaginal Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "141963", "drug_name": "azithromycin 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "141935", "drug_name": "haloperidol 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106892", "drug_name": "insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106387", "drug_name": "permethrin 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "106351", "drug_name": "silver sulfadiazine 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106346", "drug_name": "mupirocin 0.02 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "106336", "drug_name": "ketoconazole 20 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "106303", "drug_name": "tretinoin 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106302", "drug_name": "tretinoin 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106258", "drug_name": "hydrocortisone 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "105590", "drug_name": "thioguanine 40 MG Oral Tablet [Tabloid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "105585", "drug_name": "methotrexate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "105583", "drug_name": "fluorouracil 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "105553", "drug_name": "chlorambucil 2 MG Oral Tablet [Leukeran]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "105292", "drug_name": "isoniazid 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "105171", "drug_name": "cefadroxil 100 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "104894", "drug_name": "ondansetron 4 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "104884", "drug_name": "metoclopramide 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCDE", "drug_tier": "FORMULARY", "prior_authorization": false, 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