[ { "rxnorm_id": "701984", "drug_name": "mineral oil 0.425 MG/MG / petrolatum 0.568 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1188426", "drug_name": "carboxymethylcellulose sodium 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702008", "drug_name": "mineral oil 0.425 MG/MG / petrolatum 0.573 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "579907", "drug_name": "carboxymethylcellulose sodium 0.01 MG/MG Ophthalmic Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1250693", "drug_name": "loperamide hydrochloride 0.133 MG/ML Oral Suspension [Imodium]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049632", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet [Benadryl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1243440", "drug_name": "8 HR acetaminophen 650 MG Extended Release Oral Tablet [Tylenol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209459", "drug_name": "acetaminophen 500 MG Oral Tablet [Tylenol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310932", "drug_name": "hypromellose 0.003 MG/MG Ophthalmic Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "706820", "drug_name": "mineral oil 0.03 MG/MG / petrolatum 0.94 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "793204", "drug_name": "hypromellose 0.003 MG/MG Ophthalmic Gel [GenTeal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404172", "drug_name": "acetaminophen 500 MG / caffeine 65 MG Oral Tablet [Excedrin Tension Headache]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "260847", "drug_name": "aspirin 325 MG Oral Tablet [Bufferin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "848166", "drug_name": "aspirin 500 MG Oral Tablet [Bufferin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198029", "drug_name": "24 HR nicotine 0.583 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198030", "drug_name": "24 HR nicotine 0.875 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198031", "drug_name": "24 HR nicotine 0.292 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1011870", "drug_name": "nicotine 2 MG Chewing Gum [Thrive]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2751899", "drug_name": "0.3 ML SARS-CoV-2 (COVID-19) vaccine, mRNA-BNT162b2 XFG (JN.1) 0.1 MG/ML Prefilled Syringe [Comirnaty 2026-2027]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204602", "drug_name": "bacitracin 0.4 UNT/MG / neomycin 0.0035 MG/MG / polymyxin B 5 UNT/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995613", "drug_name": "ferrous sulfate 75 MG/ML Oral Solution [Fer-in-Sol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404472", "drug_name": "aluminum hydroxide 50.8 MG/ML / magnesium carbonate 47.5 MG/ML Oral Suspension [Gaviscon]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978006", "drug_name": "loperamide hydrochloride 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307668", "drug_name": "acetaminophen 32 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198440", "drug_name": "acetaminophen 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314119", "drug_name": "nicotine 2 MG Chewing Gum", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283641", "drug_name": "calcium carbonate 800 MG / famotidine 10 MG / magnesium hydroxide 165 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311975", "drug_name": "nicotine 4 MG Chewing Gum", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "992766", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream) / 3 (miconazole nitrate 200 MG Vaginal Insert) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199047", "drug_name": "famotidine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "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": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998540", "drug_name": "miconazole nitrate 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "318272", "drug_name": "aspirin 81 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "359817", "drug_name": "nicotine 2 MG Oral Lozenge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049906", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313782", "drug_name": "acetaminophen 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198380", "drug_name": "tioconazole 0.065 MG/MG Vaginal Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049630", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1148399", "drug_name": "8 HR acetaminophen 650 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283219", "drug_name": "piperonyl butoxide 40 MG/ML / pyrethrins 3.3 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "359818", "drug_name": "nicotine 4 MG Oral Lozenge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1250685", "drug_name": "loperamide hydrochloride 0.133 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "250387", "drug_name": "permethrin 10 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "212033", "drug_name": "aspirin 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736014", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Option 2]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2387532", "drug_name": "acetaminophen 250 MG / ibuprofen 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310323", "drug_name": "ferrous sulfate 60 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308891", "drug_name": "calcium carbonate 250 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245686", "drug_name": "docusate sodium 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307675", "drug_name": "acetaminophen 32 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "243463", "drug_name": "aluminum hydroxide 40 MG/ML / magnesium hydroxide 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307746", "drug_name": "aluminum hydroxide 40 MG/ML / magnesium hydroxide 40 MG/ML / simethicone 4 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237870", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308753", "drug_name": "bisacodyl 5 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115005", "drug_name": "docusate sodium 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283100", "drug_name": "sodium phosphate, dibasic 59.3 MG/ML / sodium phosphate, monobasic 161 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "730955", "drug_name": "sodium phosphate, dibasic 35.5 MG/ML / sodium phosphate, monobasic 96.4 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "210117", "drug_name": "calcium carbonate 500 MG Chewable Tablet [Tums]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1044532", "drug_name": "calcium carbonate 750 MG Chewable Tablet [Tums]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1044524", "drug_name": "calcium carbonate 1000 MG Chewable Tablet [Tums]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209326", "drug_name": "nicotine 2 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "105071", "drug_name": "nicotine 4 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351429", "drug_name": "24 HR nicotine 0.875 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351427", "drug_name": "24 HR nicotine 0.583 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "351433", "drug_name": "24 HR nicotine 0.292 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "968849", "drug_name": "nicotine 2 MG Oral Lozenge [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "968851", "drug_name": "nicotine 4 MG Oral Lozenge [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1095636", "drug_name": "acetaminophen 32 MG/ML Oral Solution [Panadol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200977", "drug_name": "acetaminophen 500 MG Oral Tablet [Panadol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1872075", "drug_name": "acetaminophen 500 MG / caffeine 65 MG Oral Tablet [Panadol Extra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309594", "drug_name": "vitamin B12 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313852", "drug_name": "adapalene 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "284245", "drug_name": "famotidine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310410", "drug_name": "folic acid 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "104094", "drug_name": "famotidine 20 MG Oral Tablet [Pepcid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "104095", "drug_name": "famotidine 40 MG Oral Tablet [Pepcid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1488047", "drug_name": "tretinoin 0.0008 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "208328", "drug_name": "tretinoin 0.25 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "208330", "drug_name": "tretinoin 0.5 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "208331", "drug_name": "tretinoin 1 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "701305", "drug_name": "tretinoin 0.00025 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "208334", "drug_name": "tretinoin 0.0001 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198859", "drug_name": "sodium bicarbonate 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198861", "drug_name": "sodium bicarbonate 650 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310324", "drug_name": "ferrous sulfate 325 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "211874", "drug_name": "aspirin 325 MG Oral Tablet [Bayer Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "825180", "drug_name": "aspirin 81 MG Chewable Tablet [Bayer Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "794229", "drug_name": "aspirin 81 MG Delayed Release Oral Tablet [Bayer Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "387090", "drug_name": "aspirin 325 MG Delayed Release Oral Tablet [Bayer Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308696", "drug_name": "benzoyl peroxide 50 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153183", "drug_name": "adapalene 0.001 MG/MG Topical Gel [Differin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "905387", "drug_name": "adapalene 1 MG/ML Topical Lotion [Differin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284420", "drug_name": "adapalene 1 MG/ML Topical Cream [Differin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "722113", "drug_name": "adapalene 0.003 MG/MG Topical Gel [Differin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "486131", "drug_name": "benzoyl peroxide 0.1 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "205121", "drug_name": "mineral oil 1000 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308762", "drug_name": "bismuth subsalicylate 17.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086767", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution [Wal-Dryl Childrens]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090076", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule [Wal-Dryl Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198509", "drug_name": "bisacodyl 10 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308915", "drug_name": "calcium carbonate 750 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308907", "drug_name": "calcium carbonate 500 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198467", "drug_name": "aspirin 325 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308416", "drug_name": "aspirin 81 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090078", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet [Wal-Dryl Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308892", "drug_name": "calcium carbonate 1000 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308763", "drug_name": "bismuth subsalicylate 35 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992775", "drug_name": "{1 (miconazole nitrate 1200 MG Vaginal Insert) / 1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307731", "drug_name": "adapalene 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "876193", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308761", "drug_name": "bismuth subsalicylate 262 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1547948", "drug_name": "carboxymethylcellulose sodium 2.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197505", "drug_name": "cimetidine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "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": "MIWRAP", "drug_tier": "COVERED", "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": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198300", "drug_name": "tretinoin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313450", "drug_name": "tretinoin 0.0001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313451", "drug_name": "tretinoin 0.00025 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "245723", "drug_name": "tretinoin 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "312564", "drug_name": "povidone-iodine 100 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237521", "drug_name": "10 ML manganese chloride 0.1 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204536", "drug_name": "10 ML cupric chloride 1.07 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204401", "drug_name": "10 ML chromic chloride 0.004 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312424", "drug_name": "0.5 ML vitamin K1 2 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1670192", "drug_name": "1 ML vitamin K1 10 MG/ML Injection", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "722111", "drug_name": "adapalene 0.003 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1313059", "drug_name": "24 HR phentermine 11.25 MG / topiramate 69 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302850", "drug_name": "24 HR phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302827", "drug_name": "24 HR phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302839", "drug_name": "24 HR phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363306", "drug_name": "chlorpheniramine maleate 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1101778", "drug_name": "monobasic potassium phosphate 0.0408 MEQ/ML Oral Solution [K-Phos]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251241", "drug_name": "potassium phosphate 155 MG / sodium phosphate, dibasic 852 MG / sodium phosphate, monobasic 130 MG Oral Tablet [K-Phos Neutral]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "210000", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension [Almacone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308078", "drug_name": "aluminum hydroxide 64 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363315", "drug_name": "chlorpheniramine maleate 4 MG Oral Tablet [Aller-Chlor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998704", "drug_name": "calcium carbonate 500 MG Chewable Tablet [Cal Gest]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310325", "drug_name": "ferrous sulfate 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308694", "drug_name": "benzoyl peroxide 0.05 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106310", "drug_name": "benzoyl peroxide 100 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308689", "drug_name": "benzoyl peroxide 0.025 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "483325", "drug_name": "levonorgestrel 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312563", "drug_name": "povidone-iodine 0.1 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1248119", "drug_name": "docusate sodium 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "251156", "drug_name": "ferrous sulfate 75 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702249", "drug_name": "ferrous sulfate 44 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "142004", "drug_name": "polyvinyl alcohol 0.014 ML/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1297389", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 200 UNT Oral Tablet [Oysco 500 with D]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1860100", "drug_name": "ferrous sulfate 324 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198300", "drug_name": "tretinoin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "106303", "drug_name": "tretinoin 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313450", "drug_name": "tretinoin 0.0001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313451", "drug_name": "tretinoin 0.00025 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198464", "drug_name": "aspirin 300 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "317106", "drug_name": "hydroxocobalamin 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198741", "drug_name": "magnesium oxide 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311430", "drug_name": "magnesium oxide 420 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313324", "drug_name": "thiamine hydrochloride 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1725059", "drug_name": "naloxone hydrochloride 40 MG/ML Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "998526", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution [Fungoid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363309", "drug_name": "chlorpheniramine maleate 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209890", "drug_name": "acetaminophen 500 MG Oral Capsule [Mapap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212033", "drug_name": "aspirin 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020477", "drug_name": "diphenhydramine hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311431", "drug_name": "magnesium oxide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020479", "drug_name": "diphenhydramine hydrochloride 50 MG Oral Capsule [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809536", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 200 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1092421", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "708127", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension [Mintox Plus]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209495", "drug_name": "acetaminophen 80 MG Chewable Tablet [Mapap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209417", "drug_name": "acetaminophen 33.3 MG/ML Oral Solution [Mapap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "543460", "drug_name": "ammonium lactate 120 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197362", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086613", "drug_name": "mineral oil 0.15 MG/MG / petrolatum 0.83 MG/MG Ophthalmic Ointment [Lubrifresh P.M.]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198102", "drug_name": "vitamin K1 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245376", "drug_name": "docusate calcium 240 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1092422", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245468", "drug_name": "docusate sodium 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307684", "drug_name": "acetaminophen 33.3 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251355", "drug_name": "aluminum hydroxide 6.33 MG/ML / magnesium carbonate 23.9 MG/ML Oral Suspension [Acid Gone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "211176", "drug_name": "bismuth subsalicylate 17.5 MG/ML Oral Suspension [Pepto-bismol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "211915", "drug_name": "bismuth subsalicylate 35 MG/ML Oral Suspension [Pepto-bismol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "211151", "drug_name": "bismuth subsalicylate 262 MG Chewable Tablet [Pepto-bismol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "208510", "drug_name": "benzoyl peroxide 0.1 MG/MG Topical Gel [Persa-Gel]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049909", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "282465", "drug_name": "calcium carbonate 1250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359345", "drug_name": "bacitracin 0.4 UNT/MG / neomycin 0.0035 MG/MG / polymyxin B 10 UNT/MG / pramoxine hydrochloride 0.01 MG/MG Topical Ointment [Lanabiotic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "876195", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [Miralax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311429", "drug_name": "magnesium oxide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "749329", "drug_name": "tretinoin 0.0005 MG/MG Topical Gel [Atralin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1367410", "drug_name": "ergocalciferol 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1491649", "drug_name": "triprolidine hydrochloride 0.938 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1293942", "drug_name": "acetaminophen 500 MG Oral Tablet [Pharbetol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298830", "drug_name": "acetaminophen 325 MG Oral Tablet [Pharbetol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2003710", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [New Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2598453", "drug_name": "vitamin B12 1 MG/ML Injectable Solution [Dodex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "688892", "drug_name": "calcium carbonate 800 MG / famotidine 10 MG / magnesium hydroxide 165 MG Chewable Tablet [Pepcid Complete]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212072", "drug_name": "famotidine 10 MG Oral Tablet [Pepcid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205643", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion [Amlactin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1488045", "drug_name": "tretinoin 0.0008 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "106258", "drug_name": "hydrocortisone 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235262", "drug_name": "mineral oil 0.2 MG/MG / petrolatum 0.8 MG/MG Ophthalmic Ointment [Soothe Night Time]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "598050", "drug_name": "polyvinyl alcohol 0.005 ML/ML / povidone 6 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308760", "drug_name": "bismuth subsalicylate 262 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199603", "drug_name": "clotrimazole 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "727625", "drug_name": "0.5 ML vitamin K1 2 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490671", "drug_name": "triprolidine hydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1926926", "drug_name": "triprolidine hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1367416", "drug_name": "ergocalciferol 1.25 MG Oral Capsule [Drisdol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702384", "drug_name": "bismuth subsalicylate 262 MG Oral Tablet [Pepto-bismol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237786", "drug_name": "folic acid 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212086", "drug_name": "aspirin 325 MG Delayed Release Oral Tablet [Ecotrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1189781", "drug_name": "aspirin 81 MG Delayed Release Oral Tablet [Ecotrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "861113", "drug_name": "vitamin B12 0.5 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "892244", "drug_name": "{14 (24 HR nicotine 0.292 MG/HR Transdermal System) / 14 (24 HR nicotine 0.583 MG/HR Transdermal System) / 28 (24 HR nicotine 0.875 MG/HR Transdermal System) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198443", "drug_name": "acetaminophen 650 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198434", "drug_name": "acetaminophen 120 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "635970", "drug_name": "ferrous sulfate 325 MG Oral Tablet [Feosol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "880407", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [ClearLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797907", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "861115", "drug_name": "vitamin B12 0.5 MG/ACTUAT Nasal Spray [Nascobal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600602", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [EContra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998525", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1010895", "drug_name": "lidocaine hydrochloride 40 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828555", "drug_name": "acetaminophen 32 MG/ML Oral Suspension [Tylenol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049910", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule [Benadryl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209387", "drug_name": "acetaminophen 325 MG Oral Tablet [Tylenol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049908", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution [Benadryl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "542045", "drug_name": "folic acid 1 MG / vitamin B12 0.5 MG Oral Tablet [Foltrate]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2262295", "drug_name": "dexbrompheniramine maleate 2 MG Oral Tablet [Ala-Hist IR]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2749389", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Your Choice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309368", "drug_name": "clotrimazole 10 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209531", "drug_name": "acetaminophen 80 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209353", "drug_name": "acetaminophen 120 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209361", "drug_name": "acetaminophen 325 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1293456", "drug_name": "tazarotene 1 MG/ML Topical Foam [Fabior]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "642346", "drug_name": "bismuth subsalicylate 17.5 MG/ML Oral Suspension [Kaopectate Reformulated Aug 2006]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1043048", "drug_name": "bismuth subsalicylate 35 MG/ML Oral Suspension [Kaopectate Reformulated Aug 2006]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2476644", "drug_name": "bismuth subsalicylate 262 MG Chewable Tablet [Kaopectate Reformulated Aug 2006]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2711894", "drug_name": "docusate sodium 250 MG Oral Capsule [Prolaxa]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1094393", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution [Siladryl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "207716", "drug_name": "24 HR nicotine 0.875 MG/HR Transdermal System [Habitrol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "284283", "drug_name": "bisacodyl 10 MG Rectal Suppository [The Magic Bullet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "245001", "drug_name": "aluminum hydroxide 50.8 MG/ML / magnesium carbonate 47.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1425181", "drug_name": "calcium carbonate 500 MG Chewable Tablet [Healthy Mama]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1235389", "drug_name": "ascorbic acid 60 MG / cholecalciferol 0.01 MG / folic acid 0.3 MG / niacin 13.5 MG / riboflavin 1.2 MG / sodium fluoride 0.55 MG / thiamine 1.05 MG / vitamin A 0.75 MG / vitamin B12 0.0045 MG / vitamin B6 1.05 MG / vitamin E 6.75 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364854", "drug_name": "ascorbic acid 60 MG / cholecalciferol 0.01 MG / folic acid 0.3 MG / niacin 13.5 MG / riboflavin 1.2 MG / sodium fluoride 1.1 MG / thiamine 1.05 MG / vitamin A 0.75 MG / vitamin B12 0.0045 MG / vitamin B6 1.05 MG / vitamin E 6.75 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1364855", "drug_name": "ascorbic acid 60 MG / cholecalciferol 0.01 MG / folic acid 0.3 MG / niacin 13.5 MG / riboflavin 1.2 MG / sodium fluoride 2.2 MG / thiamine 1.05 MG / vitamin A 0.75 MG / vitamin B12 0.0045 MG / vitamin B6 1.05 MG / vitamin E 15 UNT Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1365980", "drug_name": "ascorbic acid 35 MG/ML / cholecalciferol 0.01 MG/ML / sodium fluoride 0.55 MG/ML / vitamin A palmitate 1500 UNT/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1365984", "drug_name": "ascorbic acid 35 MG/ML / cholecalciferol 0.01 MG/ML / sodium fluoride 1.1 MG/ML / vitamin A palmitate 1500 UNT/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1234482", "drug_name": "ascorbic acid 35 MG/ML / cholecalciferol 400 UNT/ML / niacin 8 MG/ML / riboflavin 0.6 MG/ML / sodium fluoride 0.55 MG/ML / thiamine 0.5 MG/ML / vitamin A 1500 UNT/ML / vitamin B12 0.002 MG/ML / vitamin B6 0.4 MG/ML / vitamin E 5 UNT/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2106821", "drug_name": "carboxymethylcellulose sodium 2.5 MG/ML Ophthalmic Solution [TheraTears]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2179647", "drug_name": "triprolidine hydrochloride 0.625 MG/ML Oral Solution [Pediaclear Childrens]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2049533", "drug_name": "lidocaine 30 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2746503", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution [Lasolex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "579999", "drug_name": "mineral oil 0.319 MG/MG / petrolatum 0.577 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "580001", "drug_name": "mineral oil 0.415 MG/MG / petrolatum 0.568 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1088146", "drug_name": "mineral oil 0.15 MG/MG / petrolatum 0.85 MG/MG Ophthalmic Ointment [Altalube]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2540709", "drug_name": "naloxone hydrochloride 80 MG/ML Nasal Spray [Kloxxado]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1010732", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [PureLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "210958", "drug_name": "magnesium oxide 400 MG Oral Tablet [Mag-Ox 400]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1088531", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [HealthyLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302845", "drug_name": "24 HR phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302833", "drug_name": "24 HR phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1313061", "drug_name": "24 HR phentermine 11.25 MG / topiramate 69 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302856", "drug_name": "24 HR phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1549091", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Opcicon One-Step]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1922759", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [My Choice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891522", "drug_name": "ascorbic acid 100 MG / biotin 0.15 MG / calcium pantothenate 5 MG / folic acid 1 MG / niacin 20 MG / pyridoxine 10 MG / riboflavin 1.7 MG / thiamine mononitrate 1.5 MG / vitamin B12 0.006 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312736", "drug_name": "pyridoxine hydrochloride 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992778", "drug_name": "{1 (miconazole nitrate 1200 MG Vaginal Insert [Monistat]) / 1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]) } Pack [Monistat 1 Day Ovule Combination Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992771", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]) / 3 (miconazole nitrate 200 MG Vaginal Insert [Monistat]) } Pack [Monistat 3 Day Ovule Combination Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998541", "drug_name": "miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1661176", "drug_name": "tioconazole 0.065 MG/MG Vaginal Ointment [Monistat Simple Therapy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763066", "drug_name": "permethrin 10 MG/ML Medicated Shampoo [Nix Cream Rinse]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1053146", "drug_name": "mineral oil 0.319 MG/MG / petrolatum 0.577 MG/MG Ophthalmic Ointment [Stye]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997501", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797909", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Aller-Flo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "656742", "drug_name": "potassium phosphate 155 MG / sodium phosphate, dibasic 852 MG / sodium phosphate, monobasic 130 MG Oral Tablet [Phospha 250 Neutral]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1545303", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Afterpill]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245383", "drug_name": "calcium carbonate 298 MG / magnesium chloride 596 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1247756", "drug_name": "docusate sodium 100 MG Oral Capsule [Colace]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245389", "drug_name": "calcium carbonate 298 MG / magnesium chloride 596 MG Delayed Release Oral Tablet [Slow-Mag Reformulated Feb 2012]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "211108", "drug_name": "povidone-iodine 100 MG/ML Topical Solution [Betadine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1149658", "drug_name": "povidone-iodine 75 MG/ML Medicated Liquid Soap [Betadine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "108204", "drug_name": "povidone-iodine 50 MG/ML Topical Spray [Betadine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1426881", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [My Way]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1146002", "drug_name": "folic acid 2.5 MG / pyridoxine 25 MG / vitamin B12 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200251", "drug_name": "potassium phosphate 155 MG / sodium phosphate, dibasic 852 MG / sodium phosphate, monobasic 130 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2733998", "drug_name": "folic acid 0.2 MG/ML Oral Solution [Quiofic]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "858079", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Plan B One-Step]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "749795", "drug_name": "aspirin 81 MG Delayed Release Oral Tablet [St. Joseph Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "211832", "drug_name": "aspirin 81 MG Chewable Tablet [St. Joseph Aspirin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "750171", "drug_name": "bisacodyl 5 MG Delayed Release Oral Tablet [Alophen Reformulated Jan 2008]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307686", "drug_name": "acetaminophen 500 MG / caffeine 65 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "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": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1718952", "drug_name": "carboxymethylcellulose sodium 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310965", "drug_name": "ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1428927", "drug_name": "triprolidine hydrochloride 0.625 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "243670", "drug_name": "aspirin 81 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311237", "drug_name": "ketotifen 0.25 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2707361", "drug_name": "folic acid 0.2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2680741", "drug_name": "naloxone hydrochloride 16 MG/ML Nasal Spray [Rextovy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "152770", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 0.01 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209613", "drug_name": "bisacodyl 5 MG Delayed Release Oral Tablet [Dulcolax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209601", "drug_name": "bisacodyl 10 MG Rectal Suppository [Dulcolax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2609246", "drug_name": "famotidine 20 MG Oral Tablet [Zantac Reformulated Aug 2022]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1421893", "drug_name": "lidocaine 40 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "685054", "drug_name": "cholecalciferol 0.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2672491", "drug_name": "carboxymethylcellulose sodium 6 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2704898", "drug_name": "naloxone hydrochloride 90.9 MG/ML Nasal Spray [Rezenopy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014678", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997420", "drug_name": "fexofenadine hydrochloride 180 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797907", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "596843", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311277", "drug_name": "lansoprazole 30 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402014", "drug_name": "omeprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "596918", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule [Prevacid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797933", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Flonase]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309367", "drug_name": "clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "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": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1192737", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet [Wal-Fex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797929", "drug_name": "budesonide 0.032 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "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": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014674", "drug_name": "cetirizine hydrochloride 10 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997501", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "261159", "drug_name": "clotrimazole 10 MG/ML Topical Cream [Lotrimin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997502", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet [Allegra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2387532", "drug_name": "acetaminophen 250 MG / ibuprofen 125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014643", "drug_name": "cetirizine hydrochloride 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020022", "drug_name": "cetirizine hydrochloride 10 MG Chewable Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206206", "drug_name": "lansoprazole 30 MG Delayed Release Oral Capsule [Prevacid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679323", "drug_name": "0.5 ML tirzepatide 5 MG/ML Injection [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679325", "drug_name": "0.5 ML tirzepatide 10 MG/ML Injection [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679327", "drug_name": "0.5 ML tirzepatide 15 MG/ML Injection [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679317", "drug_name": "0.5 ML tirzepatide 20 MG/ML Injection [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669721", "drug_name": "0.5 ML tirzepatide 30 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669718", "drug_name": "0.5 ML tirzepatide 25 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669715", "drug_name": "0.5 ML tirzepatide 20 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669712", "drug_name": "0.5 ML tirzepatide 15 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669709", "drug_name": "0.5 ML tirzepatide 10 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2669706", "drug_name": "0.5 ML tirzepatide 5 MG/ML Auto-Injector [Zepbound]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "544393", "drug_name": "ibuprofen 20 MG/ML Oral Suspension [Motrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "606990", "drug_name": "ibuprofen 200 MG Oral Capsule [Motrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "201126", "drug_name": "ibuprofen 200 MG Oral Tablet [Motrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284380", "drug_name": "ketotifen 0.25 MG/ML Ophthalmic Solution [Zaditor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311372", "drug_name": "loratadine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204442", "drug_name": "ibuprofen 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014673", "drug_name": "cetirizine hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978010", "drug_name": "loperamide hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310964", "drug_name": "ibuprofen 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310965", "drug_name": "ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "692783", "drug_name": "loratadine 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997420", "drug_name": "fexofenadine hydrochloride 180 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849574", "drug_name": "naproxen sodium 220 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310963", "drug_name": "ibuprofen 100 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014678", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "203105", "drug_name": "hydrocortisone 0.01 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1598268", "drug_name": "Weight Management 3 ML liraglutide 6 MG/ML Pen Injector [Saxenda]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "849728", "drug_name": "naproxen sodium 220 MG Oral Tablet [Aleve]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1112233", "drug_name": "naproxen sodium 220 MG Oral Capsule [Aleve]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1437774", "drug_name": "diphenhydramine hydrochloride 1.67 MG/ML Oral Solution [Wal-Sleep Z]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "644386", "drug_name": "ibuprofen 200 MG Oral Capsule [Wal-Profen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482533", "drug_name": "cetirizine hydrochloride 1 MG/ML Oral Solution [Wal Zyr 24 Hour Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "755478", "drug_name": "loratadine 1 MG/ML Oral Solution [Wal-itin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "643102", "drug_name": "ibuprofen 200 MG Oral Tablet [Wal-Profen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1087169", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet [Wal-Zyr]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978006", "drug_name": "loperamide hydrochloride 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1087051", "drug_name": "loratadine 10 MG Oral Tablet [Wal-itin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1116528", "drug_name": "fexofenadine hydrochloride 180 MG Oral Tablet [Wal-Fex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311237", "drug_name": "ketotifen 0.25 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "103951", "drug_name": "tolnaftate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014676", "drug_name": "cetirizine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2735350", "drug_name": "Weight Management 3 ML liraglutide 6 MG/ML Pen Injector", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "900038", "drug_name": "phentermine hydrochloride 30 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978654", "drug_name": "diethylpropion hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978668", "drug_name": "24 HR diethylpropion hydrochloride 75 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "968766", "drug_name": "phentermine hydrochloride 15 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313422", "drug_name": "tolnaftate 0.01 MG/MG Topical Powder", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311373", "drug_name": "loratadine 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998483", "drug_name": "miconazole nitrate 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153008", "drug_name": "ibuprofen 200 MG Oral Tablet [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "731533", "drug_name": "ibuprofen 200 MG Oral Capsule [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206878", "drug_name": "ibuprofen 20 MG/ML Oral Suspension [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "731536", "drug_name": "ibuprofen 100 MG Chewable Tablet [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "731531", "drug_name": "ibuprofen 40 MG/ML Oral Suspension [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1810304", "drug_name": "phentermine hydrochloride 8 MG Oral Tablet [Lomaira]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "803353", "drug_name": "phentermine hydrochloride 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "803348", "drug_name": "phentermine hydrochloride 37.5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "904368", "drug_name": "benzphetamine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979549", "drug_name": "phendimetrazine tartrate 35 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "206805", "drug_name": "loratadine 10 MG Oral Tablet [Claritin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309367", "drug_name": "clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "707594", "drug_name": "ketotifen 0.25 MG/ML Ophthalmic Solution [Alaway]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198707", "drug_name": "hydrocortisone 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283641", "drug_name": "calcium carbonate 800 MG / famotidine 10 MG / magnesium hydroxide 165 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "755476", "drug_name": "loratadine 1 MG/ML Oral Solution [Claritin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997422", "drug_name": "fexofenadine hydrochloride 180 MG Oral Tablet [Allegra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997493", "drug_name": "fexofenadine hydrochloride 6 MG/ML Oral Suspension [Allegra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "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": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1112231", "drug_name": "naproxen sodium 220 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978012", "drug_name": "loperamide hydrochloride 2 MG Oral Tablet [Diamode]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020126", "drug_name": "loratadine 10 MG Oral Tablet [Loradamed]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2673691", "drug_name": "ibuprofen 200 MG Oral Capsule [Proprinal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "854762", "drug_name": "ibuprofen 40 MG/ML Oral Suspension [Motrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978013", "drug_name": "loperamide hydrochloride 2 MG Oral Tablet [Imodium]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978009", "drug_name": "loperamide hydrochloride 2 MG Oral Capsule [Imodium]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020021", "drug_name": "cetirizine hydrochloride 1 MG/ML Oral Solution [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020026", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "792242", "drug_name": "ibuprofen 100 MG Chewable Tablet [Motrin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997491", "drug_name": "fexofenadine hydrochloride 6 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "803354", "drug_name": "phentermine hydrochloride 37.5 MG Oral Tablet [Adipex-P]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "226917", "drug_name": "orlistat 120 MG Oral Capsule [Xenical]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314153", "drug_name": "orlistat 120 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "826919", "drug_name": "phentermine hydrochloride 8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1991946", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet [Aller-Tec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1043690", "drug_name": "hydrocortisone acetate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "997501", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2261754", "drug_name": "1 ML cetirizine hydrochloride 10 MG/ML Injection [Quzyttir]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "979543", "drug_name": "24 HR phendimetrazine tartrate 105 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "MIWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] } ]