[ { "rxnorm_id": "91792", "drug_name": "Oxymetholone 50 MG Oral Tablet [Anadrol-50]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "92582", "drug_name": "mometasone furoate 1 MG/ML Topical Cream [Elocon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "92583", "drug_name": "mometasone furoate 1 MG/ML Topical Lotion [Elocon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "92584", "drug_name": "mometasone furoate 0.001 MG/MG Topical Ointment [Elocon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "92752", "drug_name": "Fluorouracil 10 MG/ML Topical Cream [Fluoroplex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "93252", "drug_name": "Hydrochlorothiazide 50 MG / Triamterene 75 MG Oral Tablet [Maxzide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "93253", "drug_name": "Hydrochlorothiazide 25 MG / Triamterene 37.5 MG Oral Tablet [Maxzide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "94345", "drug_name": "Desoximetasone 2.5 MG/ML Topical Cream [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "94346", "drug_name": "Desoximetasone 0.0005 MG/MG Topical Gel [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "94348", "drug_name": "Desoximetasone 0.0025 MG/MG Topical Ointment [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "96304", "drug_name": "Primidone 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "102166", "drug_name": "Glycopyrrolate 2 MG Oral Tablet [Robinul]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103401", "drug_name": "Hydrocortisone 0.025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103403", "drug_name": "Hydrocortisone 10 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103439", "drug_name": "Desonide 0.5 MG/ML Topical Cream [Tridesilon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "103456", "drug_name": "Fluocinonide 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103457", "drug_name": "Fluocinonide 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103467", "drug_name": "Halcinonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "103899", "drug_name": "Rifabutin 150 MG Oral Capsule [Mycobutin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103918", "drug_name": "fluvastatin 20 MG Oral Capsule [Lescol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "103919", "drug_name": "fluvastatin 40 MG Oral Capsule [Lescol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "103943", "drug_name": "Ciprofloxacin 3 MG/ML Ophthalmic Solution [Ciloxan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "103956", "drug_name": "Alprostadil 0.02 MG Injection [Caverject]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104094", "drug_name": "Famotidine 20 MG Oral Tablet [Pepcid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104095", "drug_name": "Famotidine 40 MG Oral Tablet [Pepcid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104098", "drug_name": "Misoprostol 0.2 MG Oral Tablet [Cytotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104367", "drug_name": "Doxazosin 1 MG Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104368", "drug_name": "Doxazosin 2 MG Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104369", "drug_name": "Doxazosin 4 MG Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104375", "drug_name": "Lisinopril 2.5 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104376", "drug_name": "Lisinopril 5 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104377", "drug_name": "Lisinopril 10 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104378", "drug_name": "Lisinopril 20 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104384", "drug_name": "Ramipril 2.5 MG Oral Capsule [Altace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104385", "drug_name": "Ramipril 5 MG Oral Capsule [Altace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104490", "drug_name": "Simvastatin 10 MG Oral Tablet [Zocor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104491", "drug_name": "Simvastatin 20 MG Oral Tablet [Zocor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104699", "drug_name": "Diazepam 2 MG Oral Tablet [Valium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104700", "drug_name": "Diazepam 5 MG Oral Tablet [Valium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104701", "drug_name": "Diazepam 10 MG Oral Tablet [Valium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104719", "drug_name": "Lorazepam 1 MG Oral Tablet [Ativan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104775", "drug_name": "Clozapine 25 MG Oral Tablet [Clozaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104776", "drug_name": "Clozapine 100 MG Oral Tablet [Clozaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104781", "drug_name": "Risperidone 1 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104782", "drug_name": "Risperidone 2 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104783", "drug_name": "Risperidone 3 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104784", "drug_name": "Risperidone 4 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "104836", "drug_name": "Phenelzine 15 MG Oral Tablet [Nardil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104838", "drug_name": "Tranylcypromine 10 MG Oral Tablet [Parnate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104849", "drug_name": "Fluoxetine 20 MG Oral Capsule [Prozac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104884", "drug_name": "Metoclopramide 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104885", "drug_name": "nabilone 1 MG Oral Capsule [Cesamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104894", "drug_name": "Ondansetron 4 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104895", "drug_name": "Ondansetron 4 MG Oral Tablet [Zofran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "104896", "drug_name": "Ondansetron 8 MG Oral Tablet [Zofran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105018", "drug_name": "lamotrigine 100 MG Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105019", "drug_name": "lamotrigine 25 MG Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105028", "drug_name": "gabapentin 100 MG Oral Capsule [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105029", "drug_name": "gabapentin 300 MG Oral Capsule [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105030", "drug_name": "gabapentin 400 MG Oral Capsule [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105050", "drug_name": "Bromocriptine 5 MG Oral Capsule [Parlodel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105071", "drug_name": "Nicotine 4 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105171", "drug_name": "Cefadroxil 100 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105260", "drug_name": "Azithromycin 40 MG/ML Oral Suspension [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105292", "drug_name": "isoniazid 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105330", "drug_name": "terbinafine 250 MG Oral Tablet [Lamisil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "105446", "drug_name": "Bromocriptine 2.5 MG Oral Tablet [Parlodel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105450", "drug_name": "Metyrapone 250 MG Oral Capsule [Metopirone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105551", "drug_name": "Busulfan 2 MG Oral Tablet [Myleran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105553", "drug_name": "Chlorambucil 2 MG Oral Tablet [Leukeran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "105562", "drug_name": "Melphalan 2 MG Oral Tablet [Alkeran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105583", "drug_name": "Fluorouracil 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105585", "drug_name": "Methotrexate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105590", "drug_name": "Thioguanine 40 MG Oral Tablet [Tabloid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105602", "drug_name": "hydroxyurea 500 MG Oral Capsule [Hydrea]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105611", "drug_name": "Azathioprine 50 MG Oral Tablet [Imuran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105641", "drug_name": "Goserelin 3.6 MG Drug Implant [Zoladex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105648", "drug_name": "Aldesleukin 22000000 UNT Injection [Proleukin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105899", "drug_name": "Naproxen 500 MG Oral Tablet [Naprosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105929", "drug_name": "Piroxicam 10 MG Oral Capsule [Feldene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "105930", "drug_name": "Piroxicam 20 MG Oral Capsule [Feldene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106258", "drug_name": "Hydrocortisone 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106302", "drug_name": "Tretinoin 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106303", "drug_name": "Tretinoin 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106336", "drug_name": "Ketoconazole 20 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106346", "drug_name": "Mupirocin 0.02 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106351", "drug_name": "Silver Sulfadiazine 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106366", "drug_name": "Sulconazole nitrate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106387", "drug_name": "Permethrin 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106834", "drug_name": "Trimipramine 50 MG Oral Capsule [Surmontil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "106892", "drug_name": "insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108395", "drug_name": "ceftibuten 400 MG Oral Capsule [Cedax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108396", "drug_name": "20 ML Zidovudine 10 MG/ML Injection [Retrovir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108513", "drug_name": "Tacrolimus 1 MG Oral Capsule [Prograf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108514", "drug_name": "Tacrolimus 5 MG Oral Capsule [Prograf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108758", "drug_name": "Mupirocin 0.02 MG/MG Nasal Ointment [Bactroban]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108780", "drug_name": "valacyclovir 500 MG Oral Tablet [Valtrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108782", "drug_name": "lamotrigine 200 MG Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108828", "drug_name": "bicalutamide 50 MG Oral Tablet [Casodex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108852", "drug_name": "famciclovir 125 MG Oral Tablet [Famvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108896", "drug_name": "apraclonidine 5 MG/ML Ophthalmic Solution [Iopidine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "108959", "drug_name": "calcipotriene 0.05 MG/ML Topical Cream [Dovonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "141850", "drug_name": "Desoximetasone 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "141859", "drug_name": "Acyclovir 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "141927", "drug_name": "Alprazolam 0.25 MG Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "141928", "drug_name": "Alprazolam 0.5 MG Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "141935", "drug_name": "Haloperidol 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "141963", "drug_name": "Azithromycin 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "142034", "drug_name": "Benzoyl Peroxide 100 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "142046", "drug_name": "Metronidazole 0.0075 MG/MG Vaginal Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "150750", "drug_name": "Atenolol 25 MG Oral Tablet [Tenormin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "150840", "drug_name": "Estrogens, Conjugated (USP) 0.625 MG Oral Tablet [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151029", "drug_name": "mometasone furoate 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151030", "drug_name": "mometasone furoate 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151100", "drug_name": "dorzolamide 20 MG/ML Ophthalmic Solution [Trusopt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151124", "drug_name": "anastrozole 1 MG Oral Tablet [Arimidex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151226", "drug_name": "topiramate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151227", "drug_name": "topiramate 50 MG Oral Tablet [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151228", "drug_name": "topiramate 100 MG Oral Tablet [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "151229", "drug_name": "topiramate 200 MG Oral Tablet [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152414", "drug_name": "Atenolol 50 MG Oral Tablet [Tenormin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152695", "drug_name": "meloxicam 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152697", "drug_name": "meloxicam 7.5 MG Oral Tablet [Mobic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152698", "drug_name": "meloxicam 15 MG Oral Tablet [Mobic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152854", "drug_name": "Itraconazole 10 MG/ML Oral Solution [Sporanox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152855", "drug_name": "topiramate 25 MG Oral Tablet [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152880", "drug_name": "Toremifene 60 MG Oral Tablet [Fareston]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152915", "drug_name": "Riluzole 50 MG Oral Tablet [Rilutek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152923", "drug_name": "Simvastatin 40 MG Oral Tablet [Zocor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152931", "drug_name": "Lamivudine 150 MG Oral Tablet [Epivir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152932", "drug_name": "Lamivudine 10 MG/ML Oral Solution [Epivir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152941", "drug_name": "Stavudine 15 MG Oral Capsule [Zerit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152942", "drug_name": "Stavudine 20 MG Oral Capsule [Zerit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152943", "drug_name": "Stavudine 30 MG Oral Capsule [Zerit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152944", "drug_name": "Stavudine 40 MG Oral Capsule [Zerit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "152952", "drug_name": "ropinirole 0.25 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152953", "drug_name": "ropinirole 1 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152954", "drug_name": "ropinirole 2 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152955", "drug_name": "ropinirole 5 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "152971", "drug_name": "Ritonavir 80 MG/ML Oral Solution [Norvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153046", "drug_name": "olanzapine 5 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153047", "drug_name": "olanzapine 7.5 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153048", "drug_name": "olanzapine 10 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153095", "drug_name": "glucagon (rDNA) 1 MG Injection [GlucaGen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153124", "drug_name": "letrozole 2.5 MG Oral Tablet [Femara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153127", "drug_name": "Indinavir 200 MG Oral Capsule [Crixivan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153128", "drug_name": "Indinavir 400 MG Oral Capsule [Crixivan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153183", "drug_name": "adapalene 0.001 MG/MG Topical Gel [Differin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153324", "drug_name": "Interferon beta-1a 0.03 MG Injection [Avonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153353", "drug_name": "zolmitriptan 2.5 MG Oral Tablet [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153473", "drug_name": "Altretamine 50 MG Oral Capsule [Hexalen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153579", "drug_name": "Progesterone 0.04 MG/MG Vaginal Gel [Crinone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153580", "drug_name": "Progesterone 0.08 MG/MG Vaginal Gel [Crinone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153591", "drug_name": "glimepiride 2 MG Oral Tablet [Amaryl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153638", "drug_name": "quetiapine 25 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153639", "drug_name": "quetiapine 100 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153640", "drug_name": "quetiapine 200 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153652", "drug_name": "Stavudine 1 MG/ML Oral Solution [Zerit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153655", "drug_name": "tolcapone 100 MG Oral Tablet [Tasmar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153665", "drug_name": "irbesartan 75 MG Oral Tablet [Avapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153666", "drug_name": "irbesartan 150 MG Oral Tablet [Avapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153667", "drug_name": "irbesartan 300 MG Oral Tablet [Avapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "153735", "drug_name": "tizanidine 4 MG Oral Tablet [Zanaflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153843", "drug_name": "glimepiride 1 MG Oral Tablet [Amaryl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153845", "drug_name": "glimepiride 4 MG Oral Tablet [Amaryl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153892", "drug_name": "montelukast 10 MG Oral Tablet [Singulair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "153893", "drug_name": "montelukast 5 MG Chewable Tablet [Singulair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197303", "drug_name": "Acetazolamide 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197304", "drug_name": "Acetazolamide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197305", "drug_name": "Acetic Acid 20 MG/ML Otic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197310", "drug_name": "Acyclovir 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197311", "drug_name": "Acyclovir 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197313", "drug_name": "Acyclovir 800 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197316", "drug_name": "Albuterol 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197318", "drug_name": "Albuterol 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197319", "drug_name": "Allopurinol 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197320", "drug_name": "Allopurinol 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197321", "drug_name": "Alprazolam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197322", "drug_name": "Alprazolam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197327", "drug_name": "amcinonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197328", "drug_name": "amcinonide 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197351", "drug_name": "6-Aminocaproic Acid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197361", "drug_name": "Amlodipine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197362", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197363", "drug_name": "Amoxapine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197364", "drug_name": "Amoxapine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197365", "drug_name": "Amoxapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197366", "drug_name": "Amoxapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197379", "drug_name": "Atenolol 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197380", "drug_name": "Atenolol 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197381", "drug_name": "Atenolol 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197382", "drug_name": "Atenolol 100 MG / Chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197383", "drug_name": "Atenolol 50 MG / Chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197388", "drug_name": "Azathioprine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197391", "drug_name": "Baclofen 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197392", "drug_name": "Baclofen 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197397", "drug_name": "benzonatate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197405", "drug_name": "Betamethasone 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197407", "drug_name": "Betamethasone 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197408", "drug_name": "Betamethasone 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197409", "drug_name": "Betamethasone 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197411", "drug_name": "Bromocriptine 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197412", "drug_name": "Bromocriptine 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197417", "drug_name": "Bumetanide 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197418", "drug_name": "Bumetanide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197419", "drug_name": "Bumetanide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197426", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197436", "drug_name": "Captopril 25 MG / Hydrochlorothiazide 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197437", "drug_name": "Captopril 25 MG / Hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197438", "drug_name": "Captopril 50 MG / Hydrochlorothiazide 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197439", "drug_name": "Captopril 50 MG / Hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197443", "drug_name": "Carbidopa 10 MG / Levodopa 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197444", "drug_name": "Carbidopa 25 MG / Levodopa 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197445", "drug_name": "Carbidopa 25 MG / Levodopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197446", "drug_name": "Carisoprodol 350 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197447", "drug_name": "Aspirin 325 MG / Carisoprodol 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197448", "drug_name": "Levocarnitine 330 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197449", "drug_name": "Cefaclor 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197452", "drug_name": "cefprozil 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197453", "drug_name": "cefprozil 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197454", "drug_name": "Cephalexin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197464", "drug_name": "Clorazepate Dipotassium 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197465", "drug_name": "Clorazepate Dipotassium 3.75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197466", "drug_name": "Clorazepate Dipotassium 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197475", "drug_name": "Chlorothiazide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197476", "drug_name": "Chlorothiazide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197495", "drug_name": "Chlorpropamide 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197496", "drug_name": "Chlorpropamide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197499", "drug_name": "Chlorthalidone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197500", "drug_name": "Chlorthalidone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197501", "drug_name": "Chlorzoxazone 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197502", "drug_name": "Chlorzoxazone 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197505", "drug_name": "Cimetidine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197506", "drug_name": "Cimetidine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197507", "drug_name": "Cimetidine 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197508", "drug_name": "Cimetidine 800 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197511", "drug_name": "Ciprofloxacin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197512", "drug_name": "Ciprofloxacin 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197516", "drug_name": "Clarithromycin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197517", "drug_name": "Clarithromycin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197518", "drug_name": "Clindamycin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197519", "drug_name": "Clindamycin 10 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197520", "drug_name": "clocortolone 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197527", "drug_name": "Clonazepam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197528", "drug_name": "Clonazepam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197529", "drug_name": "Clonazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197535", "drug_name": "Clozapine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197536", "drug_name": "Clozapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197541", "drug_name": "Colchicine 0.6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197552", "drug_name": "Cyclosporine 100 MG Oral Capsule [Sandimmune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197553", "drug_name": "Cyclosporine 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197554", "drug_name": "Danazol 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197555", "drug_name": "Danazol 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197556", "drug_name": "Danazol 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197557", "drug_name": "Dapsone 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197558", "drug_name": "Dapsone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197572", "drug_name": "Desonide 0.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197573", "drug_name": "Desoximetasone 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197574", "drug_name": "Desoximetasone 2.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197575", "drug_name": "Desoximetasone 0.0025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197577", "drug_name": "Dexamethasone 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197579", "drug_name": "Dexamethasone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197580", "drug_name": "Dexamethasone 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197581", "drug_name": "Dexamethasone 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197582", "drug_name": "Dexamethasone 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197583", "drug_name": "Dexamethasone 6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197589", "drug_name": "Diazepam 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197590", "drug_name": "Diazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197591", "drug_name": "Diazepam 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197593", "drug_name": "Diazoxide 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197595", "drug_name": "Dicloxacillin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197596", "drug_name": "Dicloxacillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197603", "drug_name": "Diflunisal 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197604", "drug_name": "Digoxin 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197606", "drug_name": "Digoxin 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197622", "drug_name": "Dipyridamole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197623", "drug_name": "Disulfiram 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197624", "drug_name": "Disulfiram 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197625", "drug_name": "Doxazosin 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197626", "drug_name": "Doxazosin 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197627", "drug_name": "Doxazosin 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197628", "drug_name": "Doxazosin 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197634", "drug_name": "dronabinol 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197635", "drug_name": "dronabinol 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197636", "drug_name": "dronabinol 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197650", "drug_name": "Erythromycin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197653", "drug_name": "Estazolam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197654", "drug_name": "Estazolam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197657", "drug_name": "Estradiol 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197658", "drug_name": "Estradiol 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197659", "drug_name": "Estradiol 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197670", "drug_name": "Estrogens, Esterified (USP) 1.25 MG / Methyltestosterone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197682", "drug_name": "Ethosuximide 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197684", "drug_name": "Etodolac 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197685", "drug_name": "Etodolac 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197686", "drug_name": "Etodolac 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197687", "drug_name": "Etoposide 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197694", "drug_name": "Fenoprofen 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197696", "drug_name": "72 HR Fentanyl 0.075 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197698", "drug_name": "Fluconazole 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197699", "drug_name": "Fluconazole 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197700", "drug_name": "Fluconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197701", "drug_name": "Fluconazole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197718", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197719", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197720", "drug_name": "Flurandrenolide 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197724", "drug_name": "Flurbiprofen 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197725", "drug_name": "Flurbiprofen 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197726", "drug_name": "Flutamide 125 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197730", "drug_name": "Furosemide 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197731", "drug_name": "Furosemide 8 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197732", "drug_name": "Furosemide 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197735", "drug_name": "Gentamicin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197737", "drug_name": "Glyburide 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197738", "drug_name": "Glycopyrrolate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197739", "drug_name": "Glycopyrrolate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197741", "drug_name": "Guaifenesin 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197745", "drug_name": "Guanfacine 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197746", "drug_name": "Guanfacine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197754", "drug_name": "Haloperidol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197770", "drug_name": "Hydrochlorothiazide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197782", "drug_name": "Hydrocortisone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197783", "drug_name": "Hydrocortisone 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197785", "drug_name": "Hydrocortisone 25 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197787", "drug_name": "Hydrocortisone 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197797", "drug_name": "hydroxyurea 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197803", "drug_name": "Ibuprofen 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197805", "drug_name": "Ibuprofen 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197806", "drug_name": "Ibuprofen 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197807", "drug_name": "Ibuprofen 800 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197815", "drug_name": "Indapamide 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197816", "drug_name": "Indapamide 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197817", "drug_name": "Indomethacin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197818", "drug_name": "Indomethacin 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197832", "drug_name": "isoniazid 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197839", "drug_name": "Isosorbide Dinitrate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197840", "drug_name": "Isosorbide Dinitrate 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197841", "drug_name": "Isosorbide Dinitrate 5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197848", "drug_name": "Isradipine 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197849", "drug_name": "Isradipine 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197853", "drug_name": "Ketoconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197854", "drug_name": "Ketoprofen 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197855", "drug_name": "Ketoprofen 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197856", "drug_name": "Ketoprofen 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197860", "drug_name": "Leucovorin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197861", "drug_name": "Leucovorin 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197862", "drug_name": "Leucovorin 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197863", "drug_name": "Leucovorin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197873", "drug_name": "levorphanol tartrate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197877", "drug_name": "Lidocaine 25 MG/ML / Prilocaine 25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197878", "drug_name": "Lindane 10 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197884", "drug_name": "Lisinopril 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197885", "drug_name": "Hydrochlorothiazide 12.5 MG / Lisinopril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197886", "drug_name": "Hydrochlorothiazide 12.5 MG / Lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197887", "drug_name": "Hydrochlorothiazide 25 MG / Lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197889", "drug_name": "Lithium Carbonate 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197890", "drug_name": "Lithium Carbonate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197891", "drug_name": "Lithium Carbonate 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197892", "drug_name": "Lithium Carbonate 450 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197893", "drug_name": "Lithium Carbonate 600 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197900", "drug_name": "Lorazepam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197901", "drug_name": "Lorazepam 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197902", "drug_name": "Lorazepam 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197903", "drug_name": "Lovastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197904", "drug_name": "Lovastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197905", "drug_name": "Lovastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "197919", "drug_name": "Melphalan 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197928", "drug_name": "Meprobamate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197929", "drug_name": "Meprobamate 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197931", "drug_name": "mercaptopurine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197939", "drug_name": "Methazolamide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197940", "drug_name": "Methazolamide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197941", "drug_name": "Methimazole 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197942", "drug_name": "Methimazole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197943", "drug_name": "Methocarbamol 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197944", "drug_name": "Methocarbamol 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197947", "drug_name": "Methoxsalen 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197951", "drug_name": "Methyclothiazide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197956", "drug_name": "Methyldopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197958", "drug_name": "Methyldopa 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197960", "drug_name": "Hydrochlorothiazide 25 MG / Methyldopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197963", "drug_name": "Hydrochlorothiazide 15 MG / Methyldopa 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197971", "drug_name": "Methylprednisolone 32 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197973", "drug_name": "Methylprednisolone 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197975", "drug_name": "Methyltestosterone 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197978", "drug_name": "Metolazone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197979", "drug_name": "Metolazone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197980", "drug_name": "Metyrosine 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197984", "drug_name": "Minocycline 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197985", "drug_name": "Minocycline 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197986", "drug_name": "Minoxidil 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "197987", "drug_name": "Minoxidil 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198000", "drug_name": "Bendroflumethiazide 5 MG / Nadolol 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198001", "drug_name": "Bendroflumethiazide 5 MG / Nadolol 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198006", "drug_name": "Nadolol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198007", "drug_name": "Nadolol 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198008", "drug_name": "Nadolol 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198012", "drug_name": "Naproxen 375 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198013", "drug_name": "Naproxen 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198014", "drug_name": "Naproxen 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198024", "drug_name": "Niacin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198029", "drug_name": "24 HR Nicotine 0.583 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198030", "drug_name": "24 HR Nicotine 0.875 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198031", "drug_name": "24 HR Nicotine 0.292 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198032", "drug_name": "Nifedipine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198033", "drug_name": "Nifedipine 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198034", "drug_name": "24 HR Nifedipine 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198035", "drug_name": "24 HR Nifedipine 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198036", "drug_name": "24 HR Nifedipine 90 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198037", "drug_name": "Nimodipine 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198038", "drug_name": "Nitroglycerin 0.3 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198039", "drug_name": "Nitroglycerin 0.4 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198040", "drug_name": "Nitroglycerin 0.6 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198041", "drug_name": "Nizatidine 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198045", "drug_name": "Nortriptyline 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198046", "drug_name": "Nortriptyline 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198047", "drug_name": "Nortriptyline 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198049", "drug_name": "Ofloxacin 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198050", "drug_name": "Ofloxacin 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198051", "drug_name": "Omeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "198052", "drug_name": "Ondansetron 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198056", "drug_name": "Oxandrolone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198057", "drug_name": "Oxazepam 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198059", "drug_name": "Oxazepam 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198070", "drug_name": "Penicillamine 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198075", "drug_name": "Perphenazine 16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198076", "drug_name": "Perphenazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198077", "drug_name": "Perphenazine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198078", "drug_name": "Perphenazine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198083", "drug_name": "Phenobarbital 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198086", "drug_name": "Phenobarbital 16.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198089", "drug_name": "Phenobarbital 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198102", "drug_name": "vitamin K1 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198104", "drug_name": "Pindolol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198105", "drug_name": "Pindolol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198107", "drug_name": "Piroxicam 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198108", "drug_name": "Piroxicam 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198116", "drug_name": "Potassium Chloride 20 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198140", "drug_name": "Praziquantel 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198141", "drug_name": "Prazosin 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198144", "drug_name": "Prednisone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198145", "drug_name": "Prednisone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198146", "drug_name": "Prednisone 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198148", "drug_name": "Prednisone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198150", "drug_name": "Primidone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198152", "drug_name": "Probenecid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198153", "drug_name": "Colchicine 0.5 MG / Probenecid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198159", "drug_name": "Prochlorperazine 25 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198165", "drug_name": "Propantheline 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198175", "drug_name": "Propylthiouracil 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198181", "drug_name": "Pyrazinamide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198182", "drug_name": "Pyrimethamine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198188", "drug_name": "Ramipril 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198189", "drug_name": "Ramipril 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198190", "drug_name": "Ranitidine 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198191", "drug_name": "Ranitidine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198192", "drug_name": "Ranitidine 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198193", "drug_name": "Ranitidine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "198200", "drug_name": "Rifabutin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198201", "drug_name": "Rifampin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198202", "drug_name": "Rifampin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198211", "drug_name": "Simvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "198215", "drug_name": "Sodium Fluoride 0.55 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198222", "drug_name": "Spironolactone 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198223", "drug_name": "Spironolactone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198224", "drug_name": "Hydrochlorothiazide 25 MG / Spironolactone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198228", "drug_name": "Sulfadiazine 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198232", "drug_name": "Sulfasalazine 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198238", "drug_name": "Sulindac 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198239", "drug_name": "Sulindac 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198240", "drug_name": "Tamoxifen 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198241", "drug_name": "Temazepam 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198242", "drug_name": "Temazepam 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198243", "drug_name": "Temazepam 7.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198245", "drug_name": "terconazole 80 MG Vaginal Insert", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198250", "drug_name": "tetracycline hydrochloride 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198252", "drug_name": "tetracycline hydrochloride 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198270", "drug_name": "Thioridazine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198274", "drug_name": "Thioridazine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198275", "drug_name": "Thioridazine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198283", "drug_name": "Timolol 2.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198284", "drug_name": "Timolol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198285", "drug_name": "Timolol 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198286", "drug_name": "Timolol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198292", "drug_name": "Tolazamide 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198293", "drug_name": "Tolazamide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198294", "drug_name": "Tolbutamide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198295", "drug_name": "Tolmetin 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198296", "drug_name": "Tolmetin 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198297", "drug_name": "Tolmetin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198300", "drug_name": "Tretinoin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198312", "drug_name": "Triamterene 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198313", "drug_name": "Triamterene 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198314", "drug_name": "Hydrochlorothiazide 25 MG / Triamterene 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198316", "drug_name": "Hydrochlorothiazide 25 MG / Triamterene 37.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198317", "drug_name": "Triazolam 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198318", "drug_name": "Triazolam 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198322", "drug_name": "Trifluoperazine 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198323", "drug_name": "Trifluoperazine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198324", "drug_name": "Trifluoperazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198325", "drug_name": "Trifluoperazine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198332", "drug_name": "Trimethoprim 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198334", "drug_name": "Sulfamethoxazole 400 MG / Trimethoprim 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198335", "drug_name": "Sulfamethoxazole 800 MG / Trimethoprim 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198352", "drug_name": "Zidovudine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "198358", "drug_name": "felbamate 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198359", "drug_name": "felbamate 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198363", "drug_name": "prednicarbate 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198365", "drug_name": "Prochlorperazine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198369", "drug_name": "torsemide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198370", "drug_name": "torsemide 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198371", "drug_name": "torsemide 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198372", "drug_name": "torsemide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198377", "drug_name": "Tacrolimus 1 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198378", "drug_name": "Tacrolimus 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198382", "drug_name": "famciclovir 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198427", "drug_name": "lamotrigine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198428", "drug_name": "lamotrigine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198429", "drug_name": "lamotrigine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198467", "drug_name": "Aspirin 325 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198707", "drug_name": "Hydrocortisone 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "198953", "drug_name": "Vitamin B6 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199041", "drug_name": "amcinonide 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199055", "drug_name": "Metronidazole 375 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199058", "drug_name": "mycophenolate mofetil 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199119", "drug_name": "Omeprazole 10 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199123", "drug_name": "bicalutamide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199147", "drug_name": "Lamivudine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199148", "drug_name": "Lamivudine 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199149", "drug_name": "Acarbose 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199150", "drug_name": "Acarbose 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199159", "drug_name": "Tretinoin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199164", "drug_name": "Phenobarbital 97.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199167", "drug_name": "Phenobarbital 32.4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199168", "drug_name": "Phenobarbital 64.8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199192", "drug_name": "famciclovir 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199193", "drug_name": "famciclovir 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199206", "drug_name": "Riluzole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199224", "drug_name": "anastrozole 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199245", "drug_name": "glimepiride 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199246", "drug_name": "glimepiride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199247", "drug_name": "glimepiride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199351", "drug_name": "trandolapril 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199352", "drug_name": "trandolapril 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199353", "drug_name": "trandolapril 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199369", "drug_name": "Sodium phenylbutyrate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199370", "drug_name": "Ciprofloxacin 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199376", "drug_name": "potassium citrate 5 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199381", "drug_name": "potassium citrate 10 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199387", "drug_name": "Risperidone 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199390", "drug_name": "Etodolac 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199422", "drug_name": "Nevirapine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199450", "drug_name": "clobazam 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199592", "drug_name": "Tetrabenazine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199655", "drug_name": "zafirlukast 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199663", "drug_name": "Zidovudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "199689", "drug_name": "Acitretin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199690", "drug_name": "Acitretin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199703", "drug_name": "cabergoline 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199884", "drug_name": "Levofloxacin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199885", "drug_name": "Levofloxacin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199888", "drug_name": "topiramate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199889", "drug_name": "topiramate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199890", "drug_name": "topiramate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "199903", "drug_name": "Hydrochlorothiazide 12.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200031", "drug_name": "carvedilol 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200032", "drug_name": "carvedilol 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200033", "drug_name": "carvedilol 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200034", "drug_name": "olanzapine 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200060", "drug_name": "mycophenolate mofetil 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200064", "drug_name": "letrozole 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200082", "drug_name": "Lamivudine 150 MG / Zidovudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200094", "drug_name": "irbesartan 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200095", "drug_name": "irbesartan 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200096", "drug_name": "irbesartan 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200131", "drug_name": "12 HR Carbamazepine 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200132", "drug_name": "Acarbose 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200133", "drug_name": "12 HR Carbamazepine 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200193", "drug_name": "zolmitriptan 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200194", "drug_name": "zolmitriptan 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200224", "drug_name": "montelukast 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200256", "drug_name": "repaglinide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200257", "drug_name": "repaglinide 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200258", "drug_name": "repaglinide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200284", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200285", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200311", "drug_name": "Fenofibrate 67 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200327", "drug_name": "capecitabine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200328", "drug_name": "capecitabine 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200329", "drug_name": "Omeprazole 40 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200345", "drug_name": "Simvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "200346", "drug_name": "cefdinir 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200371", "drug_name": "Citalopram 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200801", "drug_name": "Furosemide 20 MG Oral Tablet [Lasix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200809", "drug_name": "Furosemide 40 MG Oral Tablet [Lasix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200817", "drug_name": "Spironolactone 50 MG Oral Tablet [Aldactone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200820", "drug_name": "Spironolactone 25 MG Oral Tablet [Aldactone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "200825", "drug_name": "Spironolactone 100 MG Oral Tablet [Aldactone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201185", "drug_name": "Mafenide 85 MG/ML Topical Cream [Sulfamylon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201219", "drug_name": "famciclovir 250 MG Oral Tablet [Famvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201239", "drug_name": "lamotrigine 5 MG Chewable Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201240", "drug_name": "lamotrigine 25 MG Chewable Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201322", "drug_name": "Atenolol 100 MG Oral Tablet [Tenormin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201337", "drug_name": "Nadolol 40 MG Oral Tablet [Corgard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201338", "drug_name": "Nadolol 80 MG Oral Tablet [Corgard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201388", "drug_name": "Metyrosine 250 MG Oral Capsule [Demser]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201625", "drug_name": "secobarbital sodium 100 MG Oral Capsule [Seconal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201653", "drug_name": "Pimozide 2 MG Oral Tablet [Orap]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201708", "drug_name": "Isocarboxazid 10 MG Oral Tablet [Marplan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201737", "drug_name": "Ethosuximide 250 MG Oral Capsule [Zarontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201747", "drug_name": "Primidone 250 MG Oral Tablet [Mysoline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201848", "drug_name": "Vancomycin 125 MG Oral Capsule [Vancocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "201849", "drug_name": "Vancomycin 250 MG Oral Capsule [Vancocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "201867", "drug_name": "Rifampin 150 MG Oral Capsule [Rifadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201868", "drug_name": "Rifampin 300 MG Oral Capsule [Rifadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201882", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 50 MG Oral Capsule [Macrodantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201883", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 100 MG Oral Capsule [Macrodantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201900", "drug_name": "Fluconazole 10 MG/ML Oral Suspension [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201901", "drug_name": "Fluconazole 40 MG/ML Oral Suspension [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201903", "drug_name": "Acyclovir 40 MG/ML Oral Suspension [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201905", "drug_name": "Acyclovir 400 MG Oral Tablet [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201907", "drug_name": "Zidovudine 100 MG Oral Capsule [Retrovir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "201912", "drug_name": "Pyrimethamine 25 MG Oral Tablet [Daraprim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "201961", "drug_name": "Finasteride 5 MG Oral Tablet [Proscar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "202088", "drug_name": "4-Aminobenzoate 500 MG Oral Capsule [Potaba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "202301", "drug_name": "Estrogens, Conjugated (USP) 1.25 MG Oral Tablet [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "203088", "drug_name": "Ketoconazole 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "203105", "drug_name": "Hydrocortisone 0.01 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204119", "drug_name": "Malathion 5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204135", "drug_name": "Desonide 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204416", "drug_name": "Haloperidol 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204423", "drug_name": "Hydrocortisone 10 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Otic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204837", "drug_name": "Coal Tar 200 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "204844", "drug_name": "Azithromycin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "204874", "drug_name": "Hydrocortisone 10 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205284", "drug_name": "leflunomide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205285", "drug_name": "leflunomide 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205290", "drug_name": "efavirenz 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205292", "drug_name": "efavirenz 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205304", "drug_name": "telmisartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205305", "drug_name": "telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205315", "drug_name": "topiramate 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205316", "drug_name": "topiramate 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205322", "drug_name": "celecoxib 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205323", "drug_name": "celecoxib 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205324", "drug_name": "modafinil 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205326", "drug_name": "Lisinopril 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205328", "drug_name": "Lamivudine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205494", "drug_name": "Anthralin 10 MG/ML Topical Cream [Drithocreme]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205529", "drug_name": "Desonide 0.5 MG/ML Topical Cream [Desowen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205532", "drug_name": "Dornase Alfa 1 MG/ML Inhalation Solution [Pulmozyme]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205533", "drug_name": "1 ML Buprenorphine 0.3 MG/ML Injection [Buprenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205534", "drug_name": "Desonide 0.5 MG/ML Topical Lotion [Desowen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205535", "drug_name": "Fluoxetine 10 MG Oral Capsule [Prozac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205544", "drug_name": "Doxazosin 8 MG Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205562", "drug_name": "Estramustine 140 MG Oral Capsule [Emcyt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205604", "drug_name": "doxycycline hyclate 100 MG Oral Capsule [Vibramycin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205610", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Lotion [Cordran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205612", "drug_name": "Flurandrenolide 0.0005 MG/MG Topical Ointment [Cordran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "205619", "drug_name": "Doxycycline Monohydrate 50 MG Oral Capsule [Monodox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205621", "drug_name": "Doxycycline Monohydrate 100 MG Oral Capsule [Monodox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205641", "drug_name": "dronabinol 2.5 MG Oral Capsule [Marinol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205642", "drug_name": "dronabinol 5 MG Oral Capsule [Marinol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205645", "drug_name": "dronabinol 10 MG Oral Capsule [Marinol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205669", "drug_name": "Dexamethasone 1 MG/ML Ophthalmic Suspension [Maxidex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205732", "drug_name": "Furosemide 80 MG Oral Tablet [Lasix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205739", "drug_name": "Echothiophate Iodide 1.25 MG/ML Ophthalmic Solution [Phospholine Iodide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205751", "drug_name": "Gemfibrozil 600 MG Oral Tablet [Lopid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205769", "drug_name": "Ciprofloxacin 250 MG Oral Tablet [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205770", "drug_name": "Ciprofloxacin 500 MG Oral Tablet [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205826", "drug_name": "Gentamicin 3 MG/ML / prednisolone acetate 10 MG/ML Ophthalmic Suspension [Pred-G]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205828", "drug_name": "Glipizide 5 MG Oral Tablet [Glucotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205830", "drug_name": "Glipizide 10 MG Oral Tablet [Glucotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205860", "drug_name": "Clarithromycin 50 MG/ML Oral Suspension [Biaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205863", "drug_name": "Clarithromycin 250 MG Oral Tablet [Biaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205866", "drug_name": "Clarithromycin 500 MG Oral Tablet [Biaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205886", "drug_name": "Glycopyrrolate 1 MG Oral Tablet [Robinul]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205904", "drug_name": "Griseofulvin 125 MG Oral Tablet [Gris-PEG]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205906", "drug_name": "Griseofulvin 250 MG Oral Tablet [Gris-PEG]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205909", "drug_name": "Estradiol 0.5 MG Oral Tablet [Estrace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205912", "drug_name": "Epoetin Alfa 10000 UNT/ML Injectable Solution [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205913", "drug_name": "Epoetin Alfa 10000 UNT/ML Injectable Solution [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205917", "drug_name": "1 ML Epoetin Alfa 2000 UNT/ML Injection [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205918", "drug_name": "1 ML Epoetin Alfa 2000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205921", "drug_name": "1 ML Epoetin Alfa 3000 UNT/ML Injection [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205922", "drug_name": "1 ML Epoetin Alfa 3000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205923", "drug_name": "1 ML Epoetin Alfa 4000 UNT/ML Injection [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "205924", "drug_name": "1 ML Epoetin Alfa 4000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206026", "drug_name": "Clioquinol 30 MG/ML / Hydrocortisone 5 MG/ML Topical Cream [Ala-Quin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206048", "drug_name": "clocortolone 1 MG/ML Topical Cream [Cloderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206075", "drug_name": "Erythromycin 250 MG Delayed Release Oral Tablet [Ery-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206078", "drug_name": "Erythromycin 333 MG Delayed Release Oral Tablet [Ery-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206080", "drug_name": "Erythromycin 500 MG Delayed Release Oral Tablet [Ery-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206101", "drug_name": "Estradiol 1 MG Oral Tablet [Estrace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206157", "drug_name": "Clonazepam 0.5 MG Oral Tablet [Klonopin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206159", "drug_name": "Clonazepam 1 MG Oral Tablet [Klonopin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206160", "drug_name": "Clonazepam 2 MG Oral Tablet [Klonopin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206193", "drug_name": "aluminum chloride 62.5 MG/ML Topical Solution [Xerac AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206201", "drug_name": "lamotrigine 150 MG Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206205", "drug_name": "lansoprazole 15 MG Disintegrating Oral Tablet [Prevacid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206206", "drug_name": "lansoprazole 30 MG Delayed Release Oral Capsule [Prevacid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206208", "drug_name": "aluminum chloride 200 MG/ML Topical Solution [Drysol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206216", "drug_name": "2 ML Iron-Dextran Complex 50 MG/ML Injection [InFed]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206241", "drug_name": "Estradiol 2 MG Oral Tablet [Estrace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206336", "drug_name": "Hydrocortisone 25 MG/ML Topical Solution [Texacort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206343", "drug_name": "Levocarnitine 100 MG/ML Oral Solution [Carnitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206346", "drug_name": "Levocarnitine 330 MG Oral Tablet [Carnitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206347", "drug_name": "Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206412", "drug_name": "Guanfacine 1 MG Oral Tablet [Tenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206413", "drug_name": "Guanfacine 2 MG Oral Tablet [Tenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206546", "drug_name": "Halcinonide 1 MG/ML Topical Cream [Halog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206548", "drug_name": "Halcinonide 0.001 MG/MG Topical Ointment [Halog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206550", "drug_name": "Halcinonide 1 MG/ML Topical Solution [Halog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "206629", "drug_name": "p-Hydroxyamphetamine 10 MG/ML / Tropicamide 2.5 MG/ML Ophthalmic Solution [Paremyd]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206698", "drug_name": "isoniazid 50 MG / Pyrazinamide 300 MG / Rifampin 120 MG Oral Tablet [Rifater]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206702", "drug_name": "isoniazid 150 MG / Rifampin 300 MG Oral Capsule [Rifamate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206714", "drug_name": "Dipyridamole 25 MG Oral Tablet [Persantine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206750", "drug_name": "Ethotoin 250 MG Oral Tablet [Peganone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206764", "drug_name": "Lisinopril 5 MG Oral Tablet [Prinivil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206765", "drug_name": "Lisinopril 10 MG Oral Tablet [Prinivil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206766", "drug_name": "Lisinopril 20 MG Oral Tablet [Prinivil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206771", "drug_name": "Lisinopril 40 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206786", "drug_name": "Lithium Carbonate 300 MG Extended Release Oral Tablet [Lithobid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206791", "drug_name": "mesalamine 250 MG Extended Release Oral Capsule [Pentasa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206792", "drug_name": "Lodoxamide 1 MG/ML Ophthalmic Solution [Alomide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206798", "drug_name": "mesalamine 66.7 MG/ML Enema [Rowasa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206821", "drug_name": "Lorazepam 0.5 MG Oral Tablet [Ativan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206828", "drug_name": "Lorazepam 2 MG Oral Tablet [Ativan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206831", "drug_name": "Etoposide 20 MG/ML Injectable Solution [Toposar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206842", "drug_name": "Isosorbide Dinitrate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206853", "drug_name": "famciclovir 500 MG Oral Tablet [Famvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206873", "drug_name": "Famotidine 8 MG/ML Oral Suspension [Pepcid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206961", "drug_name": "Nadolol 20 MG Oral Tablet [Corgard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206969", "drug_name": "Indomethacin 50 MG Rectal Suppository [Indocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206971", "drug_name": "Indomethacin 5 MG/ML Oral Suspension [Indocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "206978", "drug_name": "Ketoconazole 20 MG/ML Medicated Shampoo [Nizoral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207010", "drug_name": "Methimazole 5 MG Oral Tablet [Tapazole]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207012", "drug_name": "Methimazole 10 MG Oral Tablet [Tapazole]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207016", "drug_name": "Methocarbamol 500 MG Oral Tablet [Robaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207029", "drug_name": "Interferon Alfa-2b 6000000 UNT/ML Injectable Solution [Intron A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207035", "drug_name": "Interferon Alfa-2b 50000000 UNT Injection [Intron A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207059", "drug_name": "interferon beta-1b 0.3 MG Injection [Betaseron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207074", "drug_name": "Soft Gelatin Methoxsalen 10 MG Oral Capsule [Oxsoralen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207088", "drug_name": "methsuximide 300 MG Oral Capsule [Celontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207093", "drug_name": "Naproxen 25 MG/ML Oral Suspension [Naprosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207100", "drug_name": "Natamycin 50 MG/ML Ophthalmic Suspension [Natacyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207106", "drug_name": "Fluconazole 50 MG Oral Tablet [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207107", "drug_name": "Fluconazole 100 MG Oral Tablet [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207108", "drug_name": "Fluconazole 150 MG Oral Tablet [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207112", "drug_name": "Fluconazole 200 MG Oral Tablet [Diflucan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207125", "drug_name": "Flucytosine 250 MG Oral Capsule [Ancobon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207127", "drug_name": "Flucytosine 500 MG Oral Capsule [Ancobon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207136", "drug_name": "Methylprednisolone 2 MG Oral Tablet [Medrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207137", "drug_name": "Methylprednisolone 8 MG Oral Tablet [Medrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207138", "drug_name": "Methylprednisolone 16 MG Oral Tablet [Medrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207141", "drug_name": "Methylprednisolone 32 MG Oral Tablet [Medrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207194", "drug_name": "1 ML Octreotide 0.05 MG/ML Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207198", "drug_name": "1 ML Octreotide 0.1 MG/ML Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207199", "drug_name": "Octreotide 0.2 MG/ML Injectable Solution [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207200", "drug_name": "1 ML Octreotide 0.5 MG/ML Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207201", "drug_name": "Octreotide 1 MG/ML Injectable Solution [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207202", "drug_name": "Ofloxacin 3 MG/ML Ophthalmic Solution [Ocuflox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207214", "drug_name": "Methyltestosterone 10 MG Oral Capsule [Testred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207240", "drug_name": "Oxandrolone 2.5 MG Oral Tablet [Oxandrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207243", "drug_name": "oxaprozin 600 MG Oral Tablet [Daypro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207248", "drug_name": "oxiconazole 10 MG/ML Topical Cream [Oxistat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207249", "drug_name": "oxiconazole 10 MG/ML Topical Lotion [Oxistat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207265", "drug_name": "Metoclopramide 5 MG Oral Tablet [Reglan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207266", "drug_name": "Metoclopramide 10 MG Oral Tablet [Reglan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207273", "drug_name": "Nitroglycerin 0.02 MG/MG Topical Ointment [Nitro-Bid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207287", "drug_name": "Metronidazole 250 MG Oral Tablet [Flagyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207290", "drug_name": "Metronidazole 500 MG Oral Tablet [Flagyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207331", "drug_name": "Nitroglycerin 0.3 MG Sublingual Tablet [Nitrostat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207346", "drug_name": "Nitroglycerin 0.4 MG Sublingual Tablet [Nitrostat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207349", "drug_name": "Paroxetine Hydrochloride 20 MG Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207350", "drug_name": "Paroxetine Hydrochloride 30 MG Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207353", "drug_name": "Minocycline 50 MG Oral Capsule [Minocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207356", "drug_name": "Minocycline 100 MG Oral Capsule [Minocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207361", "drug_name": "Nitroglycerin 0.6 MG Sublingual Tablet [Nitrostat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207362", "drug_name": "Minocycline 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207364", "drug_name": "Minocycline 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207369", "drug_name": "Penicillamine 250 MG Oral Capsule [Cuprimine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207370", "drug_name": "Penicillamine 250 MG Oral Tablet [Depen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207373", "drug_name": "Mitotane 500 MG Oral Tablet [Lysodren]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207446", "drug_name": "rimexolone 10 MG/ML Ophthalmic Suspension [Vexol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207478", "drug_name": "Primidone 50 MG Oral Tablet [Mysoline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207485", "drug_name": "Permethrin 50 MG/ML Topical Cream [Elimite]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207569", "drug_name": "Dipyridamole 50 MG Oral Tablet [Persantine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207588", "drug_name": "Procarbazine 50 MG Oral Capsule [Matulane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207765", "drug_name": "Nifedipine 10 MG Oral Capsule [Procardia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207772", "drug_name": "Osmotic 24 HR Nifedipine 30 MG Extended Release Oral Tablet [Procardia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207773", "drug_name": "Osmotic 24 HR Nifedipine 60 MG Extended Release Oral Tablet [Procardia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207774", "drug_name": "Osmotic 24 HR Nifedipine 90 MG Extended Release Oral Tablet [Procardia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207790", "drug_name": "Nitrofurantoin 5 MG/ML Oral Suspension [Furadantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207791", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 25 MG Oral Capsule [Macrodantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207834", "drug_name": "Somatropin 5 MG Injection [Humatrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207836", "drug_name": "Somatropin 5 MG/ML Injectable Solution [Saizen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207839", "drug_name": "vitamin K1 5 MG Oral Tablet [Mephyton]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207840", "drug_name": "tiopronin 100 MG Oral Tablet [Thiola]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207846", "drug_name": "Tobramycin 3 MG/ML Ophthalmic Solution [Tobrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207850", "drug_name": "Tobramycin 0.003 MG/MG Ophthalmic Ointment [Tobrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207864", "drug_name": "crotamiton 100 MG/ML Topical Cream [Eurax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207889", "drug_name": "quazepam 15 MG Oral Tablet [Doral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207891", "drug_name": "quinapril 5 MG Oral Tablet [Accupril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207892", "drug_name": "quinapril 10 MG Oral Tablet [Accupril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207893", "drug_name": "quinapril 20 MG Oral Tablet [Accupril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207894", "drug_name": "crotamiton 100 MG/ML Topical Lotion [Eurax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207895", "drug_name": "quinapril 40 MG Oral Tablet [Accupril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "207949", "drug_name": "Succimer 100 MG Oral Capsule [Chemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208003", "drug_name": "Bendroflumethiazide 5 MG / Nadolol 40 MG Oral Tablet [Corzide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208029", "drug_name": "Bendroflumethiazide 5 MG / Nadolol 80 MG Oral Tablet [Corzide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208053", "drug_name": "Salsalate 500 MG Oral Tablet [Disalcid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208059", "drug_name": "Salsalate 750 MG Oral Tablet [Disalcid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208076", "drug_name": "torsemide 10 MG Oral Tablet [Demadex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208081", "drug_name": "torsemide 20 MG Oral Tablet [Demadex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208082", "drug_name": "torsemide 5 MG Oral Tablet [Demadex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208083", "drug_name": "sargramostim 0.25 MG/ML Injectable Solution [Leukine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208094", "drug_name": "Sucralfate 100 MG/ML Oral Suspension [Carafate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208097", "drug_name": "Sucralfate 1000 MG Oral Tablet [Carafate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208112", "drug_name": "Hydrochlorothiazide 25 MG / Spironolactone 25 MG Oral Tablet [Aldactazide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208116", "drug_name": "Hydrochlorothiazide 50 MG / Spironolactone 50 MG Oral Tablet [Aldactazide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208117", "drug_name": "Sulconazole nitrate 10 MG/ML Topical Cream [Exelderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208118", "drug_name": "Sulconazole nitrate 10 MG/ML Topical Solution [Exelderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208124", "drug_name": "Hydrochlorothiazide 25 MG / Triamterene 37.5 MG Oral Capsule [Dyazide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208149", "drug_name": "Sertraline 100 MG Oral Tablet [Zoloft]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208161", "drug_name": "Sertraline 50 MG Oral Tablet [Zoloft]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208185", "drug_name": "Silver Sulfadiazine 10 MG/ML Topical Cream [SSD]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208186", "drug_name": "Silver Sulfadiazine 10 MG/ML Topical Cream [Silvadene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208187", "drug_name": "Silver Sulfadiazine 10 MG/ML Topical Cream [Thermazene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208220", "drug_name": "Simvastatin 5 MG Oral Tablet [Zocor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "208266", "drug_name": "Theophylline 100 MG Extended Release Oral Tablet [Theochron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208316", "drug_name": "Dipyridamole 75 MG Oral Tablet [Persantine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208327", "drug_name": "Tretinoin 0.25 MG/ML Topical Cream [Avita]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208328", "drug_name": "Tretinoin 0.25 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208330", "drug_name": "Tretinoin 0.5 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208331", "drug_name": "Tretinoin 1 MG/ML Topical Cream [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208332", "drug_name": "Tretinoin 0.00025 MG/MG Topical Gel [Avita]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208334", "drug_name": "Tretinoin 0.0001 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208365", "drug_name": "benzonatate 100 MG Oral Capsule [Tessalon Perles]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208406", "drug_name": "Sulfamethoxazole 40 MG/ML / Trimethoprim 8 MG/ML Oral Suspension [Sulfatrim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208416", "drug_name": "Sulfamethoxazole 400 MG / Trimethoprim 80 MG Oral Tablet [Bactrim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208420", "drug_name": "Fluorometholone 2.5 MG/ML Ophthalmic Suspension [FML Forte Liquifilm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208435", "drug_name": "Sulfanilamide 150 MG/ML Vaginal Cream [AVC brand of sulfanilamide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208437", "drug_name": "Sulfasalazine 500 MG Oral Tablet [Azulfidine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208450", "drug_name": "Sumatriptan 25 MG Oral Tablet [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "208451", "drug_name": "Polymyxin B 10000 UNT/ML / Trimethoprim 1 MG/ML Ophthalmic Solution [Polytrim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208452", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Injection [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "208463", "drug_name": "Temazepam 7.5 MG Oral Capsule [Restoril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208464", "drug_name": "Temazepam 15 MG Oral Capsule [Restoril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208465", "drug_name": "Temazepam 30 MG Oral Capsule [Restoril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208513", "drug_name": "Estrogens, Conjugated (USP) 0.3 MG Oral Tablet [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208534", "drug_name": "thyroid (USP) 15 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208535", "drug_name": "thyroid (USP) 30 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208540", "drug_name": "thyroid (USP) 60 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208543", "drug_name": "thyroid (USP) 90 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208544", "drug_name": "thyroid (USP) 120 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208545", "drug_name": "thyroid (USP) 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208547", "drug_name": "thyroid (USP) 180 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208549", "drug_name": "thyroid (USP) 240 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208551", "drug_name": "thyroid (USP) 300 MG Oral Tablet [Armour Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208560", "drug_name": "Timolol 2.5 MG/ML Ophthalmic Solution [Betimol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208561", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution [Betimol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208581", "drug_name": "Trifluridine 10 MG/ML Ophthalmic Solution [Viroptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208591", "drug_name": "Dexamethasone 1 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Ophthalmic Suspension [Maxitrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208601", "drug_name": "Dexamethasone 0.001 MG/MG / Neomycin 0.0035 MG/MG / Polymyxin B 10 UNT/MG Ophthalmic Ointment [Maxitrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208645", "drug_name": "Trimipramine 100 MG Oral Capsule [Surmontil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208646", "drug_name": "Trimipramine 25 MG Oral Capsule [Surmontil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208660", "drug_name": "Tropicamide 10 MG/ML Ophthalmic Solution [Mydriacyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208674", "drug_name": "Triamterene 100 MG Oral Capsule [Dyrenium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208675", "drug_name": "Triamterene 50 MG Oral Capsule [Dyrenium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208680", "drug_name": "Hydrocortisone 5 MG Oral Tablet [Cortef]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208681", "drug_name": "Triazolam 0.25 MG Oral Tablet [Halcion]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208712", "drug_name": "Hydrocortisone 10 MG Oral Tablet [Cortef]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208720", "drug_name": "Trientine hydrochloride 250 MG Oral Capsule [Syprine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208813", "drug_name": "Dexamethasone 1 MG/ML / Tobramycin 3 MG/ML Ophthalmic Suspension [Tobradex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208816", "drug_name": "Hydrocortisone 20 MG Oral Tablet [Cortef]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208821", "drug_name": "Dexamethasone 0.001 MG/MG / Tobramycin 0.003 MG/MG Ophthalmic Ointment [Tobradex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208949", "drug_name": "Estrogens, Conjugated (USP) 0.9 MG Oral Tablet [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208975", "drug_name": "Praziquantel 600 MG Oral Tablet [Biltricide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208979", "drug_name": "Prazosin 1 MG Oral Capsule [Minipress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208980", "drug_name": "Prazosin 2 MG Oral Capsule [Minipress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208981", "drug_name": "Prazosin 5 MG Oral Capsule [Minipress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "208982", "drug_name": "prednicarbate 1 MG/ML Topical Cream [Dermatop]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209002", "drug_name": "prednisolone 1.2 MG/ML Ophthalmic Suspension [Pred Mild]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209006", "drug_name": "Calcitriol 0.00025 MG Oral Capsule [Rocaltrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209007", "drug_name": "Calcitriol 0.0005 MG Oral Capsule [Rocaltrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209026", "drug_name": "felbamate 400 MG Oral Tablet [Felbatol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209027", "drug_name": "felbamate 600 MG Oral Tablet [Felbatol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209028", "drug_name": "felbamate 120 MG/ML Oral Suspension [Felbatol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209066", "drug_name": "Disopyramide 100 MG Oral Capsule [Norpace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209169", "drug_name": "Sumatriptan 50 MG Oral Tablet [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "209177", "drug_name": "Misoprostol 0.1 MG Oral Tablet [Cytotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209224", "drug_name": "potassium phosphate 305 MG / Sodium Phosphate, Monobasic 700 MG Oral Tablet [K-Phos No 2]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209247", "drug_name": "Acarbose 50 MG Oral Tablet [Precose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209248", "drug_name": "Acarbose 100 MG Oral Tablet [Precose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209283", "drug_name": "terconazole 4 MG/ML Vaginal Cream [Terazol 7]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209284", "drug_name": "terconazole 8 MG/ML Vaginal Cream [Terazol 3]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209326", "drug_name": "Nicotine 2 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209329", "drug_name": "Nortriptyline 10 MG Oral Capsule [Pamelor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209339", "drug_name": "Nortriptyline 25 MG Oral Capsule [Pamelor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209350", "drug_name": "Nortriptyline 50 MG Oral Capsule [Pamelor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209391", "drug_name": "Nortriptyline 75 MG Oral Capsule [Pamelor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209692", "drug_name": "Disopyramide 150 MG Oral Capsule [Norpace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209788", "drug_name": "Cysteamine 150 MG Oral Capsule [Cystagon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209789", "drug_name": "Cysteamine 50 MG Oral Capsule [Cystagon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209826", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG Oral Tablet [Marten-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "209977", "drug_name": "Acyclovir 0.05 MG/MG Topical Ointment [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "210628", "drug_name": "Disulfiram 250 MG Oral Tablet [Antabuse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "210671", "drug_name": "trandolapril 1 MG Oral Tablet [Mavik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "210672", "drug_name": "trandolapril 2 MG Oral Tablet [Mavik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "210710", "drug_name": "Trichloroacetate 800 MG/ML Topical Solution [Tri-Chlor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "210716", "drug_name": "Disulfiram 500 MG Oral Tablet [Antabuse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211020", "drug_name": "apraclonidine 10 MG/ML Ophthalmic Solution [Iopidine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211140", "drug_name": "Pentosan Polysulfate 100 MG Oral Capsule [Elmiron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211148", "drug_name": "Albendazole 200 MG Oral Tablet [Albenza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211161", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Capsule [Esgic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211167", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Capsule [Margesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211189", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Tablet [Esgic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211190", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Tablet [Fioricet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211275", "drug_name": "Sodium Fluoride 2 MG/ML Mouthwash [Prevident Dental Rinse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211307", "drug_name": "Azithromycin 20 MG/ML Oral Suspension [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211310", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Capsule [Fiorinal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211322", "drug_name": "Mirtazapine 15 MG Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211323", "drug_name": "Mirtazapine 30 MG Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211327", "drug_name": "Nevirapine 200 MG Oral Tablet [Viramune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "211343", "drug_name": "penciclovir 10 MG/ML Topical Cream [Denavir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211465", "drug_name": "6-Aminocaproic Acid 500 MG Oral Tablet [Amicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211489", "drug_name": "Risperidone 1 MG/ML Oral Solution [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "211511", "drug_name": "Azithromycin 600 MG Oral Tablet [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211544", "drug_name": "Goserelin 10.8 MG Drug Implant [Zoladex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211666", "drug_name": "Metronidazole 7.5 MG/ML Topical Cream [MetroCream]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211699", "drug_name": "Paroxetine Hydrochloride 10 MG Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211700", "drug_name": "Paroxetine Hydrochloride 40 MG Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211759", "drug_name": "Hydrochlorothiazide 12.5 MG Oral Capsule [Microzide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211765", "drug_name": "Benzoyl Peroxide 50 MG/ML / Hydrocortisone 5 MG/ML Topical Lotion [Vanoxide-HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211776", "drug_name": "zafirlukast 20 MG Oral Tablet [Accolate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211777", "drug_name": "zileuton 600 MG Oral Tablet [Zyflo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211815", "drug_name": "Levofloxacin 250 MG Oral Tablet [Levaquin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211816", "drug_name": "Levofloxacin 500 MG Oral Tablet [Levaquin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211817", "drug_name": "Carbamazepine 200 MG Oral Tablet [Epitol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211947", "drug_name": "Atovaquone 150 MG/ML Oral Suspension [Mepron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "211979", "drug_name": "Cefuroxime 500 MG Oral Tablet [Ceftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212039", "drug_name": "Estrogens, Esterified (USP) 0.3 MG Oral Tablet [Menest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212086", "drug_name": "Aspirin 325 MG Delayed Release Oral Tablet [Ecotrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212118", "drug_name": "Nelfinavir 250 MG Oral Tablet [Viracept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "212218", "drug_name": "Epoetin Alfa 20000 UNT/ML Injectable Solution [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212219", "drug_name": "Epoetin Alfa 20000 UNT/ML Injectable Solution [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212232", "drug_name": "Estrogens, Esterified (USP) 0.625 MG Oral Tablet [Menest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212233", "drug_name": "Sertraline 25 MG Oral Tablet [Zoloft]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212306", "drug_name": "Cephalexin 250 MG Oral Capsule [Keflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212339", "drug_name": "Cephalexin 500 MG Oral Capsule [Keflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212373", "drug_name": "Estrogens, Esterified (USP) 1.25 MG Oral Tablet [Menest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212374", "drug_name": "Ergocalciferol 0.2 MG/ML Oral Solution [Drisdol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212381", "drug_name": "aminosalicylic acid 4000 MG Oral Granules [Paser D/R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212388", "drug_name": "carvedilol 6.25 MG Oral Tablet [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212389", "drug_name": "carvedilol 12.5 MG Oral Tablet [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212390", "drug_name": "carvedilol 25 MG Oral Tablet [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212405", "drug_name": "olanzapine 2.5 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "212437", "drug_name": "tazarotene 0.0005 MG/MG Topical Gel [Tazorac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212438", "drug_name": "tazarotene 0.001 MG/MG Topical Gel [Tazorac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212446", "drug_name": "Azithromycin 250 MG Oral Tablet [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212447", "drug_name": "Ondansetron 0.8 MG/ML Oral Solution [Zofran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212448", "drug_name": "valacyclovir 1000 MG Oral Tablet [Valtrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212464", "drug_name": "Estrogens, Esterified (USP) 2.5 MG Oral Tablet [Menest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212542", "drug_name": "Amlodipine 2.5 MG Oral Tablet [Norvasc]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212549", "drug_name": "Amlodipine 5 MG Oral Tablet [Norvasc]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212575", "drug_name": "Amlodipine 10 MG Oral Tablet [Norvasc]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212787", "drug_name": "Cimetidine 60 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212810", "drug_name": "Cyclosporine 25 MG Oral Capsule [Sandimmune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "212957", "drug_name": "Cyclosporine 100 MG/ML Oral Solution [Sandimmune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213045", "drug_name": "Fluorouracil 50 MG/ML Topical Cream [Efudex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213049", "drug_name": "Zinc Acetate 25 MG Oral Capsule [Galzin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213050", "drug_name": "Zinc Acetate 50 MG Oral Capsule [Galzin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213068", "drug_name": "ropinirole 0.5 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213069", "drug_name": "Acitretin 10 MG Oral Capsule [Soriatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213070", "drug_name": "Acitretin 25 MG Oral Capsule [Soriatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213082", "drug_name": "Benzoyl Peroxide 0.05 MG/MG / Erythromycin 0.03 MG/MG Topical Gel [Benzamycin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213088", "drug_name": "Lamivudine 150 MG / Zidovudine 300 MG Oral Tablet [Combivir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213091", "drug_name": "Dolasetron 50 MG Oral Tablet [Anzemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213092", "drug_name": "Dolasetron 100 MG Oral Tablet [Anzemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213120", "drug_name": "Metronidazole 10 MG/ML Topical Cream [Noritate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213167", "drug_name": "zolmitriptan 5 MG Oral Tablet [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213169", "drug_name": "clopidogrel 75 MG Oral Tablet [Plavix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213170", "drug_name": "Acarbose 25 MG Oral Tablet [Precose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213182", "drug_name": "Mupirocin 20 MG/ML Topical Cream [Bactroban]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213194", "drug_name": "Tobramycin 60 MG/ML Inhalation Solution [Tobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213196", "drug_name": "Sodium phenylbutyrate 500 MG Oral Tablet [Buphenyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213197", "drug_name": "Becaplermin 0.0001 MG/MG Topical Gel [Regranex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213204", "drug_name": "emedastine 0.5 MG/ML Ophthalmic Solution [Emadine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213211", "drug_name": "naratriptan 1 MG Oral Tablet [Amerge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213212", "drug_name": "naratriptan 2.5 MG Oral Tablet [Amerge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213218", "drug_name": "repaglinide 0.5 MG Oral Tablet [Prandin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213219", "drug_name": "repaglinide 1 MG Oral Tablet [Prandin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213220", "drug_name": "repaglinide 2 MG Oral Tablet [Prandin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213224", "drug_name": "Ciprofloxacin 50 MG/ML Oral Suspension [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213226", "drug_name": "Ciprofloxacin 100 MG/ML Oral Suspension [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213262", "drug_name": "loteprednol etabonate 2 MG/ML Ophthalmic Suspension [Alrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213263", "drug_name": "loteprednol etabonate 5 MG/ML Ophthalmic Suspension [Lotemax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213269", "drug_name": "sildenafil 25 MG Oral Tablet [Viagra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213270", "drug_name": "sildenafil 50 MG Oral Tablet [Viagra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213271", "drug_name": "sildenafil 100 MG Oral Tablet [Viagra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213272", "drug_name": "brinzolamide 10 MG/ML Ophthalmic Suspension [Azopt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213280", "drug_name": "dorzolamide 20 MG/ML / Timolol 5 MG/ML Ophthalmic Solution [Cosopt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213282", "drug_name": "hydroxyurea 200 MG Oral Capsule [Droxia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213283", "drug_name": "hydroxyurea 300 MG Oral Capsule [Droxia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213284", "drug_name": "hydroxyurea 400 MG Oral Capsule [Droxia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213291", "drug_name": "Paroxetine Hydrochloride 2 MG/ML Oral Suspension [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213292", "drug_name": "capecitabine 150 MG Oral Tablet [Xeloda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213293", "drug_name": "capecitabine 500 MG Oral Tablet [Xeloda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213298", "drug_name": "paricalcitol 0.005 MG/ML Injectable Solution [Zemplar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213307", "drug_name": "Ciprofloxacin 0.003 MG/MG Ophthalmic Ointment [Ciloxan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213319", "drug_name": "Simvastatin 80 MG Oral Tablet [Zocor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213320", "drug_name": "Ciprofloxacin 2 MG/ML / Hydrocortisone 10 MG/ML Otic Suspension [Cipro HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213321", "drug_name": "rizatriptan 5 MG Oral Tablet [Maxalt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213322", "drug_name": "rizatriptan 10 MG Oral Tablet [Maxalt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213337", "drug_name": "Sacrosidase 8500 UNT/ML Oral Solution [Sucraid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213344", "drug_name": "Citalopram 20 MG Oral Tablet [Celexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213345", "drug_name": "Citalopram 40 MG Oral Tablet [Celexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213360", "drug_name": "Thalidomide 50 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213377", "drug_name": "leflunomide 10 MG Oral Tablet [Arava]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213379", "drug_name": "leflunomide 20 MG Oral Tablet [Arava]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213390", "drug_name": "efavirenz 200 MG Oral Capsule [Sustiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213392", "drug_name": "efavirenz 50 MG Oral Capsule [Sustiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213405", "drug_name": "Nevirapine 10 MG/ML Oral Suspension [Viramune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213431", "drug_name": "telmisartan 40 MG Oral Tablet [Micardis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213432", "drug_name": "telmisartan 80 MG Oral Tablet [Micardis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213439", "drug_name": "Chlorothiazide 50 MG/ML Oral Suspension [Diuril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213442", "drug_name": "insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Novolin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213460", "drug_name": "abacavir 300 MG Oral Tablet [Ziagen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213461", "drug_name": "abacavir 20 MG/ML Oral Solution [Ziagen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213468", "drug_name": "celecoxib 100 MG Oral Capsule [Celebrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213469", "drug_name": "celecoxib 200 MG Oral Capsule [Celebrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213471", "drug_name": "modafinil 200 MG Oral Tablet [Provigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213475", "drug_name": "1 ML Epoetin Alfa 40000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213482", "drug_name": "Lisinopril 30 MG Oral Tablet [Zestril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213483", "drug_name": "Lamivudine 100 MG Oral Tablet [Epivir HBV]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213484", "drug_name": "Lamivudine 5 MG/ML Oral Solution [Epivir HBV]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "213485", "drug_name": "miglitol 25 MG Oral Tablet [Glyset]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213486", "drug_name": "miglitol 50 MG Oral Tablet [Glyset]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213487", "drug_name": "miglitol 100 MG Oral Tablet [Glyset]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213502", "drug_name": "alitretinoin 0.001 MG/MG Topical Gel [Panretin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213510", "drug_name": "Auranofin 3 MG Oral Capsule [Ridaura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213525", "drug_name": "Acetic Acid 20 MG/ML / Hydrocortisone 10 MG/ML Otic Solution [Acetasol HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213557", "drug_name": "acetohydroxamic acid 250 MG Oral Tablet [Lithostat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213570", "drug_name": "salmon calcitonin 200 UNT/ML Injectable Solution [Miacalcin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213641", "drug_name": "Betamethasone 0.5 MG/ML / Clotrimazole 10 MG/ML Topical Cream [Lotrisone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213694", "drug_name": "Acyclovir 200 MG Oral Capsule [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213695", "drug_name": "Carisoprodol 350 MG Oral Tablet [Soma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213706", "drug_name": "Acyclovir 800 MG Oral Tablet [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213729", "drug_name": "Betaxolol 2.5 MG/ML Ophthalmic Suspension [Betoptic S]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213995", "drug_name": "Allopurinol 100 MG Oral Tablet [Zyloprim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "213998", "drug_name": "Allopurinol 300 MG Oral Tablet [Zyloprim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "214003", "drug_name": "Alprazolam 1 MG Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "214004", "drug_name": "Alprazolam 2 MG Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "214097", "drug_name": "Chlorzoxazone 500 MG Oral Tablet [Parafon Forte DSC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226343", "drug_name": "Dexamethasone phosphate 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226426", "drug_name": "modafinil 100 MG Oral Tablet [Provigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "226552", "drug_name": "72 HR Scopolamine 0.0139 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226665", "drug_name": "rivastigmine 1.5 MG Oral Capsule [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226666", "drug_name": "rivastigmine 3 MG Oral Capsule [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226667", "drug_name": "rivastigmine 4.5 MG Oral Capsule [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226668", "drug_name": "rivastigmine 6 MG Oral Capsule [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226734", "drug_name": "imiquimod 50 MG/ML Topical Cream [Aldara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226827", "drug_name": "Azithromycin 500 MG Oral Tablet [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "226917", "drug_name": "orlistat 120 MG Oral Capsule [Xenical]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "226922", "drug_name": "Alprostadil 0.04 MG Injection [Caverject]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "237178", "drug_name": "Theophylline 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "237212", "drug_name": "1 ML Alprostadil 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238003", "drug_name": "168 HR Estradiol 0.00208 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "238004", "drug_name": "168 HR Estradiol 0.00417 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "238006", "drug_name": "Estrogens, Esterified (USP) 0.625 MG / Methyltestosterone 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238129", "drug_name": "1 ML Buprenorphine 0.3 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238134", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238135", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238151", "drug_name": "mesalamine 66.7 MG/ML Enema", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238154", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "238470", "drug_name": "Sodium Hydroxide 100 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "238920", "drug_name": "Betamethasone 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "239191", "drug_name": "Amoxicillin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "239210", "drug_name": "Vancomycin 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "239238", "drug_name": "Griseofulvin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "239239", "drug_name": "Griseofulvin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "239353", "drug_name": "Glutaral 250 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "240209", "drug_name": "Betamethasone 0.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "240548", "drug_name": "glycolate 700 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "240741", "drug_name": "Clarithromycin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "241527", "drug_name": "168 HR Estradiol 0.00312 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "241834", "drug_name": "cyclosporine, modified 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242120", "drug_name": "Insulin Lispro 100 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242333", "drug_name": "168 HR Estradiol 0.00104 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "242438", "drug_name": "montelukast 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242446", "drug_name": "Ofloxacin 3 MG/ML Otic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242461", "drug_name": "cilostazol 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242462", "drug_name": "cilostazol 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242679", "drug_name": "abacavir 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "242680", "drug_name": "abacavir 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "242736", "drug_name": "Metronidazole 7.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "242754", "drug_name": "Levalbuterol 0.417 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "244374", "drug_name": "Benzoyl Peroxide 0.05 MG/MG / Erythromycin 0.03 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "244967", "drug_name": "Polymyxin B 10000 UNT/ML / Trimethoprim 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "245134", "drug_name": "72 HR Fentanyl 0.025 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "245135", "drug_name": "72 HR Fentanyl 0.05 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "245136", "drug_name": "72 HR Fentanyl 0.1 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "245314", "drug_name": "Albuterol 5 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "245785", "drug_name": "Triamcinolone 0.055 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "246172", "drug_name": "clobazam 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "248109", "drug_name": "Ribavirin 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "248642", "drug_name": "Fluoxetine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "248656", "drug_name": "Azithromycin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "250344", "drug_name": "ciclopirox 10 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "250820", "drug_name": "Vigabatrin 500 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "251322", "drug_name": "Ethosuximide 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "251872", "drug_name": "pantoprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "252559", "drug_name": "Budesonide 0.5 MG/ML Inhalation Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "259255", "drug_name": "atorvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "259306", "drug_name": "alosetron 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "259966", "drug_name": "Methylprednisolone 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260218", "drug_name": "modafinil 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "260260", "drug_name": "Carbidopa 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260285", "drug_name": "Gentamicin 0.003 MG/MG / prednisolone acetate 0.006 MG/MG Ophthalmic Ointment [Pred-G]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260311", "drug_name": "Hydrocortisone 10 MG/ML Rectal Cream [Proctocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260330", "drug_name": "Methylprednisolone 4 MG Oral Tablet [Medrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260333", "drug_name": "Ramipril 10 MG Oral Capsule [Altace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260376", "drug_name": "Terazosin 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "260409", "drug_name": "prednisolone 1 MG/ML Oral Solution [Pediapred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261021", "drug_name": "Polysaccharide iron complex 150 MG Oral Capsule [Nu-Iron 150]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261101", "drug_name": "rifapentine 150 MG Oral Tablet [Priftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261105", "drug_name": "Etanercept 25 MG/ML Injectable Solution [Enbrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261106", "drug_name": "Fentanyl 0.2 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261107", "drug_name": "Fentanyl 0.6 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261108", "drug_name": "Fentanyl 0.8 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261109", "drug_name": "Fentanyl 1.2 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261110", "drug_name": "Fentanyl 1.6 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261119", "drug_name": "Metronidazole 7.5 MG/ML Topical Lotion [MetroLotion]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261134", "drug_name": "Tacrolimus 0.5 MG Oral Capsule [Prograf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261135", "drug_name": "Mirtazapine 45 MG Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261136", "drug_name": "Levalbuterol 0.21 MG/ML Inhalation Solution [Xopenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261184", "drug_name": "72 HR Fentanyl 0.025 MG/HR Transdermal System [Duragesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261185", "drug_name": "72 HR Fentanyl 0.05 MG/HR Transdermal System [Duragesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261186", "drug_name": "72 HR Fentanyl 0.075 MG/HR Transdermal System [Duragesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261204", "drug_name": "salmon calcitonin 200 UNT/ACTUAT Nasal Spray [Miacalcin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261214", "drug_name": "Clotrimazole 10 MG/ML Vaginal Cream [Gyne-Lotrimin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261241", "drug_name": "rosiglitazone 2 MG Oral Tablet [Avandia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261242", "drug_name": "rosiglitazone 4 MG Oral Tablet [Avandia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261247", "drug_name": "Doxercalciferol 0.0025 MG Oral Capsule [Hectorol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261249", "drug_name": "Malathion 5 MG/ML Topical Lotion [Ovide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261266", "drug_name": "pioglitazone 15 MG Oral Tablet [Actos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261267", "drug_name": "pioglitazone 30 MG Oral Tablet [Actos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261268", "drug_name": "pioglitazone 45 MG Oral Tablet [Actos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261280", "drug_name": "gabapentin 600 MG Oral Tablet [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261281", "drug_name": "gabapentin 800 MG Oral Tablet [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261283", "drug_name": "Calcitriol 0.001 MG/ML Oral Solution [Rocaltrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261285", "drug_name": "zaleplon 5 MG Oral Capsule [Sonata]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261286", "drug_name": "zaleplon 10 MG Oral Capsule [Sonata]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261287", "drug_name": "Fluoxetine 40 MG Oral Capsule [Prozac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261288", "drug_name": "temozolomide 5 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261289", "drug_name": "temozolomide 20 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261290", "drug_name": "temozolomide 100 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261291", "drug_name": "temozolomide 250 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261309", "drug_name": "ropinirole 4 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261313", "drug_name": "zafirlukast 10 MG Oral Tablet [Accolate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261314", "drug_name": "Ivermectin 3 MG Oral Tablet [Stromectol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261315", "drug_name": "Oseltamivir 75 MG Oral Capsule [Tamiflu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261317", "drug_name": "exemestane 25 MG Oral Tablet [Aromasin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261318", "drug_name": "entacapone 200 MG Oral Tablet [Comtan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261319", "drug_name": "Progesterone 200 MG Oral Capsule [Prometrium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261330", "drug_name": "Carbidopa 25 MG Oral Tablet [Lodosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261335", "drug_name": "Levetiracetam 250 MG Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261336", "drug_name": "Levetiracetam 500 MG Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261337", "drug_name": "olanzapine 15 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261339", "drug_name": "moxifloxacin 400 MG Oral Tablet [Avelox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261345", "drug_name": "ciclopirox 80 MG/ML Topical Solution [Penlac Nail Lacquer]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261349", "drug_name": "bexarotene 75 MG Oral Capsule [Targretin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261353", "drug_name": "Trimethoprim 10 MG/ML Oral Solution [Primsol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261356", "drug_name": "oxcarbazepine 150 MG Oral Tablet [Trileptal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261360", "drug_name": "oxcarbazepine 300 MG Oral Tablet [Trileptal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261361", "drug_name": "cevimeline 30 MG Oral Capsule [Evoxac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261362", "drug_name": "alosetron 1 MG Oral Tablet [Lotronex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "261367", "drug_name": "montelukast 4 MG Chewable Tablet [Singulair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261386", "drug_name": "ferrous gluconate 240 MG Oral Tablet [Fergon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "261962", "drug_name": "Ramipril 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "262071", "drug_name": "72 HR Fentanyl 0.1 MG/HR Transdermal System [Duragesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262077", "drug_name": "Risperidone 0.25 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262080", "drug_name": "Progesterone 100 MG Oral Capsule [Prometrium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "262090", "drug_name": "oxcarbazepine 600 MG Oral Tablet [Trileptal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "262091", "drug_name": "linezolid 600 MG Oral Tablet [Zyvox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262095", "drug_name": "atorvastatin 80 MG Oral Tablet [Lipitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262219", "drug_name": "Fentanyl 0.4 MG Oral Lozenge [Actiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262222", "drug_name": "Risperidone 0.5 MG Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "262226", "drug_name": "Pimozide 1 MG Oral Tablet [Orap]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "282401", "drug_name": "lamotrigine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "282755", "drug_name": "telmisartan 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283077", "drug_name": "prednisolone 3 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283406", "drug_name": "Mirtazapine 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283407", "drug_name": "Mirtazapine 30 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283417", "drug_name": "benzonatate 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283485", "drug_name": "Mirtazapine 45 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283535", "drug_name": "doxycycline hyclate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283536", "drug_name": "oxcarbazepine 60 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283639", "drug_name": "olanzapine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "283669", "drug_name": "pantoprazole 40 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "283672", "drug_name": "Citalopram 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "283858", "drug_name": "ropinirole 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284008", "drug_name": "travoprost 0.04 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284183", "drug_name": "Didanosine 125 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284184", "drug_name": "Didanosine 250 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284185", "drug_name": "Didanosine 200 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284191", "drug_name": "Fluorouracil 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284215", "drug_name": "Clindamycin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284245", "drug_name": "Famotidine 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284254", "drug_name": "Prochlorperazine 25 MG Rectal Suppository [Compro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284378", "drug_name": "84 HR Estradiol 0.00104 MG/HR Transdermal System [Vivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284391", "drug_name": "Levetiracetam 750 MG Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284400", "drug_name": "pantoprazole 40 MG Delayed Release Oral Tablet [Protonix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284404", "drug_name": "dofetilide 0.125 MG Oral Capsule [Tikosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284405", "drug_name": "dofetilide 0.25 MG Oral Capsule [Tikosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284408", "drug_name": "zonisamide 100 MG Oral Capsule [Zonegran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284411", "drug_name": "Doxercalciferol 0.002 MG/ML Injectable Solution [Hectorol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284419", "drug_name": "Follitropin Alfa 75 UNT Injection [Gonal F]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284420", "drug_name": "adapalene 1 MG/ML Topical Cream [Differin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284441", "drug_name": "cetrorelix 0.25 MG Injection [Cetrotide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284460", "drug_name": "Sumatriptan 100 MG Oral Tablet [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284481", "drug_name": "Levofloxacin 750 MG Oral Tablet [Levaquin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284496", "drug_name": "tazarotene 0.5 MG/ML Topical Cream [Tazorac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284497", "drug_name": "tazarotene 1 MG/ML Topical Cream [Tazorac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284498", "drug_name": "Didanosine 125 MG Delayed Release Oral Capsule [Videx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284499", "drug_name": "Didanosine 200 MG Delayed Release Oral Capsule [Videx EC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284500", "drug_name": "Didanosine 400 MG Delayed Release Oral Capsule [Videx EC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284509", "drug_name": "quetiapine 300 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284514", "drug_name": "olanzapine 20 MG Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284520", "drug_name": "Tacrolimus 0.001 MG/MG Topical Ointment [Protopic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284521", "drug_name": "Tacrolimus 0.0003 MG/MG Topical Ointment [Protopic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284529", "drug_name": "nateglinide 60 MG Oral Tablet [Starlix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284530", "drug_name": "nateglinide 120 MG Oral Tablet [Starlix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284531", "drug_name": "telmisartan 20 MG Oral Tablet [Micardis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284539", "drug_name": "Fluorouracil 5 MG/ML Topical Cream [Carac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284544", "drug_name": "Benzoyl Peroxide 0.05 MG/MG / Clindamycin 0.01 MG/MG Topical Gel [Benzaclin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284548", "drug_name": "ziprasidone 40 MG Oral Capsule [Geodon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284549", "drug_name": "ziprasidone 60 MG Oral Capsule [Geodon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284550", "drug_name": "ziprasidone 80 MG Oral Capsule [Geodon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284551", "drug_name": "nilutamide 150 MG Oral Tablet [Nilandron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284587", "drug_name": "valganciclovir 450 MG Oral Tablet [Valcyte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284588", "drug_name": "almotriptan 6.25 MG Oral Tablet [Axert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284589", "drug_name": "almotriptan 12.5 MG Oral Tablet [Axert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "284591", "drug_name": "Citalopram 10 MG Oral Tablet [Celexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284592", "drug_name": "Methotrexate 5 MG Oral Tablet [Trexall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284593", "drug_name": "Methotrexate 10 MG Oral Tablet [Trexall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284594", "drug_name": "Methotrexate 7.5 MG Oral Tablet [Trexall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284595", "drug_name": "Methotrexate 15 MG Oral Tablet [Trexall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "284988", "drug_name": "Didanosine 400 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "285016", "drug_name": "dofetilide 0.5 MG Oral Capsule [Tikosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "285018", "drug_name": "Insulin Glargine 100 UNT/ML Injectable Solution [Lantus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "285024", "drug_name": "Mafenide 50 MG/ML Topical Solution [Sulfamylon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "285027", "drug_name": "Didanosine 250 MG Delayed Release Oral Capsule [Videx EC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "285028", "drug_name": "abacavir 300 MG / Lamivudine 150 MG / Zidovudine 300 MG Oral Tablet [Trizivir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "285032", "drug_name": "travoprost 0.04 MG/ML Ophthalmic Solution [Travatan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "285127", "drug_name": "ziprasidone 20 MG Oral Capsule [Geodon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "307650", "drug_name": "abacavir 300 MG / Lamivudine 150 MG / Zidovudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "307718", "drug_name": "Acetylcysteine 100 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "307719", "drug_name": "Acetylcysteine 200 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "307730", "drug_name": "Acyclovir 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "307731", "drug_name": "adapalene 0.001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308047", "drug_name": "Alprazolam 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "308048", "drug_name": "Alprazolam 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308135", "drug_name": "Amlodipine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308136", "drug_name": "Amlodipine 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308177", "drug_name": "Amoxicillin 125 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308182", "drug_name": "Amoxicillin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308188", "drug_name": "Amoxicillin 400 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308189", "drug_name": "Amoxicillin 80 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308191", "drug_name": "Amoxicillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308192", "drug_name": "Amoxicillin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308194", "drug_name": "Amoxicillin 875 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308210", "drug_name": "Ampicillin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308212", "drug_name": "Ampicillin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308345", "drug_name": "apraclonidine 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308416", "drug_name": "Aspirin 81 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308459", "drug_name": "Azithromycin 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308460", "drug_name": "Azithromycin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308493", "drug_name": "Bacitracin 0.4 UNT/MG / Neomycin 0.0035 MG/MG / Polymyxin B 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308508", "drug_name": "Bacitracin 0.5 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308511", "drug_name": "Bacitracin 0.5 UNT/MG / Polymyxin B 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308694", "drug_name": "Benzoyl Peroxide 0.05 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308714", "drug_name": "Betamethasone 0.5 MG/ML / Clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308715", "drug_name": "Betamethasone 0.5 MG/ML / Clotrimazole 10 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308720", "drug_name": "Betaxolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308725", "drug_name": "bexarotene 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308739", "drug_name": "bimatoprost 0.3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "308865", "drug_name": "calcipotriene 0.05 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308867", "drug_name": "Calcitriol 0.00025 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308868", "drug_name": "Calcitriol 0.0005 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308869", "drug_name": "1 ML Calcitriol 0.001 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308962", "drug_name": "Captopril 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308963", "drug_name": "Captopril 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308964", "drug_name": "Captopril 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308971", "drug_name": "Carbamazepine 20 MG/ML Oral Suspension [Tegretol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308972", "drug_name": "Carbamazepine 200 MG Oral Tablet [Tegretol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308973", "drug_name": "Carbamazepine 100 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308976", "drug_name": "Carbamazepine 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308977", "drug_name": "12 HR Carbamazepine 200 MG Extended Release Oral Capsule [Carbatrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308979", "drug_name": "Carbamazepine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308988", "drug_name": "Carbidopa 25 MG / Levodopa 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "308989", "drug_name": "Carbidopa 50 MG / Levodopa 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309042", "drug_name": "Cefaclor 75 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309043", "drug_name": "12 HR Cefaclor 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309044", "drug_name": "Cefaclor 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309045", "drug_name": "Cefaclor 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309047", "drug_name": "Cefadroxil 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309048", "drug_name": "Cefadroxil 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309049", "drug_name": "Cefadroxil 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309054", "drug_name": "cefdinir 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309058", "drug_name": "Cefixime 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309076", "drug_name": "cefpodoxime 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309077", "drug_name": "cefpodoxime 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309078", "drug_name": "cefpodoxime 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309079", "drug_name": "cefpodoxime 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309080", "drug_name": "cefprozil 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309081", "drug_name": "cefprozil 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309097", "drug_name": "Cefuroxime 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309098", "drug_name": "Cefuroxime 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309110", "drug_name": "Cephalexin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309112", "drug_name": "Cephalexin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309113", "drug_name": "Cephalexin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309114", "drug_name": "Cephalexin 500 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309115", "drug_name": "Cephalexin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309140", "drug_name": "cevimeline 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309273", "drug_name": "choline salicylate 58.6 MG/ML / Magnesium Salicylate 72.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309289", "drug_name": "ciclopirox 7.7 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309290", "drug_name": "ciclopirox 7.7 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309291", "drug_name": "ciclopirox 80 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309307", "drug_name": "Ciprofloxacin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309309", "drug_name": "Ciprofloxacin 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309313", "drug_name": "Citalopram 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309314", "drug_name": "Citalopram 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309322", "drug_name": "Clarithromycin 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309332", "drug_name": "Clindamycin 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309333", "drug_name": "Clindamycin 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309337", "drug_name": "Clindamycin 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309362", "drug_name": "clopidogrel 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309367", "drug_name": "Clotrimazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309370", "drug_name": "Clotrimazole 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309371", "drug_name": "Clotrimazole 10 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309374", "drug_name": "Clozapine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "309594", "drug_name": "vitamin B12 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309632", "drug_name": "Cyclosporine 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309679", "drug_name": "Dexamethasone 0.001 MG/MG / Neomycin 0.0035 MG/MG / Polymyxin B 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309680", "drug_name": "Dexamethasone 1 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309683", "drug_name": "Dexamethasone 1 MG/ML / Tobramycin 3 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309686", "drug_name": "Dexamethasone 0.1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309843", "drug_name": "Diazepam 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309888", "drug_name": "Digoxin 0.125 MG Oral Tablet [Lanoxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309889", "drug_name": "Digoxin 0.25 MG Oral Tablet [Lanoxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309952", "drug_name": "Dipyridamole 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309955", "drug_name": "Dipyridamole 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309958", "drug_name": "Disopyramide 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "309960", "drug_name": "Disopyramide 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310015", "drug_name": "dorzolamide 20 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310140", "drug_name": "eprosartan 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310149", "drug_name": "Erythromycin 0.005 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310152", "drug_name": "Erythromycin 0.02 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310154", "drug_name": "Erythromycin 250 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310155", "drug_name": "Erythromycin 250 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310157", "drug_name": "Erythromycin 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310170", "drug_name": "168 HR Estradiol 0.00104 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310172", "drug_name": "84 HR Estradiol 0.00156 MG/HR Transdermal System [Vivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310173", "drug_name": "84 HR Estradiol 0.00208 MG/HR Transdermal System [Alora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310174", "drug_name": "168 HR Estradiol 0.00208 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310176", "drug_name": "84 HR Estradiol 0.00208 MG/HR Transdermal System [Vivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310178", "drug_name": "168 HR Estradiol 0.00312 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310180", "drug_name": "84 HR Estradiol 0.00417 MG/HR Transdermal System [Alora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310181", "drug_name": "168 HR Estradiol 0.00417 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310183", "drug_name": "84 HR Estradiol 0.00417 MG/HR Transdermal System [Vivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310212", "drug_name": "estropipate 0.75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310213", "drug_name": "estropipate 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310215", "drug_name": "estropipate 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310245", "drug_name": "24 HR Etodolac 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310247", "drug_name": "24 HR Etodolac 600 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310248", "drug_name": "Etoposide 20 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310261", "drug_name": "exemestane 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310273", "drug_name": "Famotidine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310285", "drug_name": "felbamate 120 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310288", "drug_name": "Fenofibrate 134 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310289", "drug_name": "Fenofibrate 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310291", "drug_name": "Fenoprofen 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310293", "drug_name": "Fentanyl 1.2 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310294", "drug_name": "Fentanyl 1.6 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310295", "drug_name": "Fentanyl 0.2 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310297", "drug_name": "Fentanyl 0.4 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310346", "drug_name": "Finasteride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310352", "drug_name": "Fluconazole 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310353", "drug_name": "Fluconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310362", "drug_name": "Fluocinonide 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310364", "drug_name": "Fluocinonide 0.5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310377", "drug_name": "Fluorometholone 1 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310379", "drug_name": "Fluorouracil 20 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310380", "drug_name": "Fluorouracil 50 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310384", "drug_name": "Fluoxetine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310385", "drug_name": "Fluoxetine 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310386", "drug_name": "Fluoxetine 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310404", "drug_name": "fluvastatin 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310405", "drug_name": "fluvastatin 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310429", "drug_name": "Furosemide 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310430", "drug_name": "gabapentin 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310431", "drug_name": "gabapentin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310432", "drug_name": "gabapentin 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310433", "drug_name": "gabapentin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310434", "drug_name": "gabapentin 800 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310436", "drug_name": "Galantamine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310437", "drug_name": "Galantamine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310459", "drug_name": "Gemfibrozil 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310465", "drug_name": "Gentamicin 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310466", "drug_name": "Gentamicin 0.003 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310467", "drug_name": "Gentamicin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310488", "drug_name": "Glipizide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310489", "drug_name": "24 HR Glipizide 2.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310490", "drug_name": "Glipizide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310497", "drug_name": "glucagon (rDNA) 1 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310534", "drug_name": "Glyburide 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310536", "drug_name": "Glyburide 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310537", "drug_name": "Glyburide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310539", "drug_name": "Glyburide 6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310594", "drug_name": "Gramicidin 0.025 MG/ML / Neomycin 1.75 MG/ML / Polymyxin B 10000 UNT/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310599", "drug_name": "Granisetron 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310670", "drug_name": "Haloperidol 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310671", "drug_name": "Haloperidol 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310672", "drug_name": "Haloperidol 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310687", "drug_name": "Hydrocortisone 10 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Otic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310792", "drug_name": "Hydrochlorothiazide 12.5 MG / irbesartan 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310793", "drug_name": "Hydrochlorothiazide 12.5 MG / irbesartan 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "310796", "drug_name": "Hydrochlorothiazide 12.5 MG / quinapril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310797", "drug_name": "Hydrochlorothiazide 12.5 MG / quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310798", "drug_name": "Hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310809", "drug_name": "Hydrochlorothiazide 25 MG / quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310812", "drug_name": "Hydrochlorothiazide 25 MG / Triamterene 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310818", "drug_name": "Hydrochlorothiazide 50 MG / Triamterene 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310868", "drug_name": "Hydrocortisone 10 MG/ML Rectal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310870", "drug_name": "Hydrocortisone 10 MG/ML / Iodoquinol 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310878", "drug_name": "Hydrocortisone 1.67 MG/ML Enema", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310879", "drug_name": "Hydrocortisone 25 MG/ML Rectal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310891", "drug_name": "Hydrocortisone 25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310982", "drug_name": "imiquimod 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "310992", "drug_name": "Indomethacin 75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311026", "drug_name": "insulin isophane, human 100 UNT/ML Injectable Suspension [Humulin N]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311027", "drug_name": "insulin isophane, human 100 UNT/ML Injectable Suspension [Novolin N]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311033", "drug_name": "insulin, regular, human 100 UNT/ML Injectable Solution [Novolin R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311036", "drug_name": "insulin, regular, human 100 UNT/ML Injectable Solution [Humulin R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311040", "drug_name": "insulin aspart, human 100 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311166", "drug_name": "isoniazid 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311192", "drug_name": "Isosorbide Mononitrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311194", "drug_name": "Isosorbide Dinitrate 40 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311196", "drug_name": "24 HR Isosorbide Mononitrate 120 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311197", "drug_name": "Isosorbide Mononitrate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311204", "drug_name": "Itraconazole 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311237", "drug_name": "Ketotifen 0.25 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311249", "drug_name": "Lactic acid 100 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311264", "drug_name": "lamotrigine 25 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311265", "drug_name": "lamotrigine 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311277", "drug_name": "lansoprazole 30 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311286", "drug_name": "Levalbuterol 0.21 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311288", "drug_name": "Levetiracetam 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311289", "drug_name": "Levetiracetam 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311290", "drug_name": "Levetiracetam 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311296", "drug_name": "Levofloxacin 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311347", "drug_name": "linezolid 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311353", "drug_name": "Lisinopril 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311354", "drug_name": "Lisinopril 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311355", "drug_name": "Lithium Carbonate 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311369", "drug_name": "lopinavir 80 MG/ML / Ritonavir 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311376", "drug_name": "Lorazepam 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311382", "drug_name": "loteprednol etabonate 5 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311385", "drug_name": "Loxapine 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311386", "drug_name": "Loxapine 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311486", "drug_name": "meloxicam 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311665", "drug_name": "Metipranolol 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311666", "drug_name": "Metoclopramide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311668", "drug_name": "Metoclopramide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311671", "drug_name": "Metolazone 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311678", "drug_name": "Metronidazole 7.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311679", "drug_name": "Metronidazole 0.0075 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311681", "drug_name": "Metronidazole 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311725", "drug_name": "Mirtazapine 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311726", "drug_name": "Mirtazapine 45 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311727", "drug_name": "Misoprostol 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311753", "drug_name": "mometasone furoate 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311759", "drug_name": "montelukast 4 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311787", "drug_name": "moxifloxacin 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311877", "drug_name": "Mupirocin 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311892", "drug_name": "nabumetone 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311893", "drug_name": "nabumetone 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311913", "drug_name": "Naproxen 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311915", "drug_name": "Naproxen 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311918", "drug_name": "naratriptan 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311919", "drug_name": "nateglinide 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311943", "drug_name": "Nevirapine 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "311944", "drug_name": "Niacin 500 MG Oral Tablet [Niacor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311975", "drug_name": "Nicotine 4 MG Chewing Gum", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311982", "drug_name": "nilutamide 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311984", "drug_name": "24 HR Nisoldipine 20 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311985", "drug_name": "24 HR Nisoldipine 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311989", "drug_name": "Nitrofurantoin 5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "311995", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312013", "drug_name": "Nitroglycerin 2.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312018", "drug_name": "Nitroglycerin 6.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312020", "drug_name": "Nitroglycerin 9 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312025", "drug_name": "Nizatidine 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312036", "drug_name": "Nortriptyline 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312055", "drug_name": "Nystatin 100000 UNT/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312059", "drug_name": "Nystatin 500000 UNT Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312068", "drug_name": "1 ML Octreotide 0.05 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312069", "drug_name": "1 ML Octreotide 0.1 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312070", "drug_name": "1 ML Octreotide 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312071", "drug_name": "Octreotide 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312075", "drug_name": "Ofloxacin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312076", "drug_name": "olanzapine 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312077", "drug_name": "olanzapine 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312078", "drug_name": "olanzapine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312079", "drug_name": "olanzapine 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312084", "drug_name": "Ondansetron 24 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312085", "drug_name": "Ondansetron 0.8 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312086", "drug_name": "Ondansetron 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312087", "drug_name": "Ondansetron 8 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312107", "drug_name": "Belladonna Alkaloids 16.2 MG / Opium 60 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312122", "drug_name": "Oseltamivir 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312132", "drug_name": "oxaprozin 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312134", "drug_name": "Oxazepam 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312136", "drug_name": "oxcarbazepine 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312137", "drug_name": "oxcarbazepine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312138", "drug_name": "oxcarbazepine 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312139", "drug_name": "oxiconazole 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312289", "drug_name": "Naloxone 0.5 MG / Pentazocine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312301", "drug_name": "Pentoxifylline 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312347", "drug_name": "Phenelzine 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312357", "drug_name": "Phenobarbital 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312362", "drug_name": "Phenobarbital 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312440", "drug_name": "pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312441", "drug_name": "pioglitazone 45 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312504", "drug_name": "Potassium Chloride 10 MEQ Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312529", "drug_name": "Potassium Chloride 8 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312538", "drug_name": "Potassium Hydroxide 50 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312593", "drug_name": "Prazosin 1 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312594", "drug_name": "Prazosin 2 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312614", "drug_name": "prednisolone 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312615", "drug_name": "Prednisone 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312617", "drug_name": "Prednisone 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312635", "drug_name": "Prochlorperazine 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312743", "drug_name": "quetiapine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312744", "drug_name": "quetiapine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312745", "drug_name": "quetiapine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312748", "drug_name": "quinapril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312749", "drug_name": "quinapril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312750", "drug_name": "quinapril 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312817", "drug_name": "Ribavirin 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312828", "drug_name": "Risperidone 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312829", "drug_name": "Risperidone 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312830", "drug_name": "Risperidone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312831", "drug_name": "Risperidone 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312832", "drug_name": "Risperidone 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312835", "drug_name": "rivastigmine 3 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312836", "drug_name": "rivastigmine 6 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312837", "drug_name": "rizatriptan 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312839", "drug_name": "rizatriptan 5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312840", "drug_name": "rizatriptan 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312845", "drug_name": "ropinirole 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312846", "drug_name": "ropinirole 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312847", "drug_name": "ropinirole 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312849", "drug_name": "ropinirole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312899", "drug_name": "Salsalate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312938", "drug_name": "Sertraline 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312940", "drug_name": "Sertraline 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312941", "drug_name": "Sertraline 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312950", "drug_name": "sildenafil 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312952", "drug_name": "Silver Nitrate 5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312954", "drug_name": "Silver Nitrate 250 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312955", "drug_name": "Silver Nitrate 500 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "312961", "drug_name": "Simvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "312962", "drug_name": "Simvastatin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313002", "drug_name": "Sodium Chloride 9 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313072", "drug_name": "Sodium polystyrene sulfonate 250 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313092", "drug_name": "Sorbitol 700 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313096", "drug_name": "Spironolactone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313107", "drug_name": "Stavudine 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313108", "drug_name": "Stavudine 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313109", "drug_name": "Stavudine 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313110", "drug_name": "Stavudine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313123", "drug_name": "Sucralfate 100 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313125", "drug_name": "Sulconazole nitrate 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313134", "drug_name": "Sulfamethoxazole 40 MG/ML / Trimethoprim 8 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313142", "drug_name": "Sulfasalazine 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313159", "drug_name": "Sumatriptan 5 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313160", "drug_name": "Sumatriptan 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313161", "drug_name": "Sumatriptan 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313165", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313189", "drug_name": "Tacrolimus 0.0003 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313190", "drug_name": "Tacrolimus 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313195", "drug_name": "Tamoxifen 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313209", "drug_name": "temozolomide 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313210", "drug_name": "temozolomide 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313211", "drug_name": "temozolomide 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313215", "drug_name": "Terazosin 1 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313217", "drug_name": "Terazosin 2 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313219", "drug_name": "Terazosin 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313222", "drug_name": "terbinafine 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313226", "drug_name": "terconazole 4 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313227", "drug_name": "terconazole 8 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313277", "drug_name": "Theophylline 200 MG Extended Release Oral Tablet [Theochron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313291", "drug_name": "Theophylline 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313306", "drug_name": "Theophylline 5.33 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313354", "drug_name": "Thioridazine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313361", "drug_name": "Thiothixene 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313362", "drug_name": "Thiothixene 1 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313364", "drug_name": "Thiothixene 2 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313366", "drug_name": "Thiothixene 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313406", "drug_name": "Ticlopidine Hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313407", "drug_name": "Timolol 0.0025 MG/MG Ophthalmic Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313408", "drug_name": "Timolol 0.005 MG/MG Ophthalmic Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313409", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313412", "drug_name": "tizanidine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313413", "drug_name": "tizanidine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313415", "drug_name": "Tobramycin 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313428", "drug_name": "Toremifene 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313447", "drug_name": "Tranylcypromine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313450", "drug_name": "Tretinoin 0.0001 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313451", "drug_name": "Tretinoin 0.00025 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313477", "drug_name": "Trifluridine 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313521", "drug_name": "Tropicamide 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313564", "drug_name": "valacyclovir 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313565", "drug_name": "valacyclovir 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313566", "drug_name": "valganciclovir 450 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313570", "drug_name": "Vancomycin 125 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313571", "drug_name": "Vancomycin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313580", "drug_name": "venlafaxine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313581", "drug_name": "24 HR venlafaxine 150 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313582", "drug_name": "venlafaxine 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313583", "drug_name": "24 HR venlafaxine 37.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313584", "drug_name": "venlafaxine 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313585", "drug_name": "24 HR venlafaxine 75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313586", "drug_name": "venlafaxine 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313758", "drug_name": "zafirlukast 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313761", "drug_name": "zaleplon 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313762", "drug_name": "zaleplon 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313776", "drug_name": "ziprasidone 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313777", "drug_name": "ziprasidone 60 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313778", "drug_name": "ziprasidone 80 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313786", "drug_name": "Acetic Acid 20 MG/ML / Hydrocortisone 10 MG/ML Otic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313797", "drug_name": "Amoxicillin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313799", "drug_name": "Ampicillin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313800", "drug_name": "Ampicillin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313850", "drug_name": "Amoxicillin 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313852", "drug_name": "adapalene 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313888", "drug_name": "Cefaclor 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313919", "drug_name": "salmon calcitonin 200 UNT/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313921", "drug_name": "calcipotriene 0.05 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313931", "drug_name": "12 HR Carbamazepine 300 MG Extended Release Oral Capsule [Carbatrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313932", "drug_name": "Calcitriol 0.001 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313941", "drug_name": "ciclopirox 0.0077 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313954", "drug_name": "dorzolamide 20 MG/ML / Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313979", "drug_name": "fludrocortisone acetate 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313988", "drug_name": "Furosemide 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313989", "drug_name": "Fluoxetine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313990", "drug_name": "Fluoxetine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "313992", "drug_name": "Fentanyl 0.6 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "313993", "drug_name": "Fentanyl 0.8 MG Oral Lozenge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314000", "drug_name": "Glyburide 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314006", "drug_name": "24 HR Glipizide 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314034", "drug_name": "Haloperidol 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314035", "drug_name": "Haloperidol 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314055", "drug_name": "Isosorbide Dinitrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314072", "drug_name": "latanoprost 0.05 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314075", "drug_name": "Loxapine 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314076", "drug_name": "Lisinopril 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314077", "drug_name": "Lisinopril 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314078", "drug_name": "Loxapine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314080", "drug_name": "Levofloxacin 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314088", "drug_name": "methscopolamine bromide 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314106", "drug_name": "Metronidazole 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314108", "drug_name": "Minocycline 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314111", "drug_name": "Mirtazapine 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314119", "drug_name": "Nicotine 2 MG Chewing Gum", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314135", "drug_name": "naratriptan 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314142", "drug_name": "nateglinide 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314152", "drug_name": "Octreotide 0.2 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314154", "drug_name": "olanzapine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314155", "drug_name": "olanzapine 5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314165", "drug_name": "prednisolone 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314182", "drug_name": "Potassium Chloride 2.67 MEQ/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314184", "drug_name": "Paromomycin 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314192", "drug_name": "2 ML Prochlorperazine 5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314200", "drug_name": "pantoprazole 40 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314203", "drug_name": "quinapril 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314208", "drug_name": "ropinirole 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314209", "drug_name": "rizatriptan 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314211", "drug_name": "Risperidone 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314214", "drug_name": "rivastigmine 1.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314215", "drug_name": "rivastigmine 4.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314227", "drug_name": "Sumatriptan 20 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314228", "drug_name": "sildenafil 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314229", "drug_name": "sildenafil 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314230", "drug_name": "Sirolimus 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314231", "drug_name": "Simvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "314234", "drug_name": "Sucralfate 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314238", "drug_name": "Tropicamide 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314241", "drug_name": "Theophylline 450 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314266", "drug_name": "Tacrolimus 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314267", "drug_name": "thyroid (USP) 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314277", "drug_name": "venlafaxine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314285", "drug_name": "zonisamide 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "314286", "drug_name": "ziprasidone 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "315059", "drug_name": "Desoximetasone 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315090", "drug_name": "Erythromycin 333 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315107", "drug_name": "24 HR Glipizide 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315134", "drug_name": "Levocarnitine 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315183", "drug_name": "Potassium Chloride 8 MEQ Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315187", "drug_name": "Prednisone 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "315223", "drug_name": "Sumatriptan 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "317094", "drug_name": "entacapone 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317106", "drug_name": "Hydroxocobalamin 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317110", "drug_name": "24 HR Isosorbide Mononitrate 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317128", "drug_name": "Misoprostol 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317136", "drug_name": "Nortriptyline 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317160", "drug_name": "temozolomide 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317173", "drug_name": "Captopril 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317174", "drug_name": "quetiapine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "317573", "drug_name": "pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "317769", "drug_name": "Theophylline 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "318179", "drug_name": "ergoloid mesylates, USP 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "318202", "drug_name": "Erythromycin 20 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "328160", "drug_name": "Cyclosporine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "328161", "drug_name": "Methylprednisolone 16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "343033", "drug_name": "Dexamethasone 0.75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "346574", "drug_name": "Theophylline 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "348472", "drug_name": "Theophylline 600 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "348506", "drug_name": "Itraconazole 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "348719", "drug_name": "Tobramycin 60 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349094", "drug_name": "Budesonide 0.125 MG/ML Inhalation Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349194", "drug_name": "Clonazepam 0.125 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349195", "drug_name": "Clonazepam 0.25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349196", "drug_name": "Clonazepam 1 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349197", "drug_name": "Clonazepam 2 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349198", "drug_name": "Clonazepam 0.5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349199", "drug_name": "valsartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349200", "drug_name": "valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349201", "drug_name": "valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349208", "drug_name": "Sirolimus 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349251", "drug_name": "Tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349253", "drug_name": "bosentan 62.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349287", "drug_name": "Fenofibrate 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349332", "drug_name": "Escitalopram 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349351", "drug_name": "Desonide 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349353", "drug_name": "Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349373", "drug_name": "Olmesartan medoxomil 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349401", "drug_name": "Olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349405", "drug_name": "Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349434", "drug_name": "voriconazole 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349435", "drug_name": "voriconazole 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349477", "drug_name": "efavirenz 600 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349483", "drug_name": "valsartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349490", "drug_name": "aripiprazole 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349491", "drug_name": "Lamivudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349514", "drug_name": "celecoxib 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349545", "drug_name": "aripiprazole 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349547", "drug_name": "aripiprazole 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349553", "drug_name": "aripiprazole 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349556", "drug_name": "ezetimibe 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349590", "drug_name": "Levalbuterol 0.103 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "349591", "drug_name": "atomoxetine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349592", "drug_name": "atomoxetine 18 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349593", "drug_name": "atomoxetine 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349594", "drug_name": "atomoxetine 40 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "349595", "drug_name": "atomoxetine 60 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351107", "drug_name": "olanzapine 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351108", "drug_name": "olanzapine 20 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351109", "drug_name": "Budesonide 0.25 MG/ML Inhalation Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351133", "drug_name": "Fenofibrate 54 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351136", "drug_name": "Albuterol 0.417 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351137", "drug_name": "Albuterol 0.21 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351172", "drug_name": "Dutasteride 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351173", "drug_name": "nitisinone 2 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351174", "drug_name": "nitisinone 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351175", "drug_name": "nitisinone 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351249", "drug_name": "Escitalopram 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351250", "drug_name": "Escitalopram 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351254", "drug_name": "metaxalone 800 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351256", "drug_name": "eplerenone 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351257", "drug_name": "eplerenone 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351260", "drug_name": "lansoprazole 30 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351261", "drug_name": "lansoprazole 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351264", "drug_name": "Buprenorphine 2 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351265", "drug_name": "Buprenorphine 8 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351266", "drug_name": "Buprenorphine 2 MG / Naloxone 0.5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351267", "drug_name": "Buprenorphine 8 MG / Naloxone 2 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351276", "drug_name": "Oxandrolone 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351285", "drug_name": "Escitalopram 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351297", "drug_name": "insulin aspart protamine, human 70 UNT/ML / insulin aspart, human 30 UNT/ML Injectable Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351330", "drug_name": "Clindamycin 0.01 MG/MG Topical Gel [Clindagel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351380", "drug_name": "ciclopirox 7.7 MG/ML Topical Cream [Loprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351381", "drug_name": "Isosorbide Dinitrate 40 MG Extended Release Oral Tablet [Isochron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351383", "drug_name": "ciclopirox 7.7 MG/ML Topical Lotion [Loprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351427", "drug_name": "24 HR Nicotine 0.583 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351429", "drug_name": "24 HR Nicotine 0.875 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351433", "drug_name": "24 HR Nicotine 0.292 MG/HR Transdermal System [Nicoderm C-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351438", "drug_name": "Osmotic 24 HR Nifedipine 60 MG Extended Release Oral Tablet [Nifedical]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351706", "drug_name": "Hydrocortisone 10 MG/ML / Iodoquinol 10 MG/ML Topical Cream [Dermazene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351750", "drug_name": "podofilox 0.005 MG/MG Topical Gel [Condylox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351761", "drug_name": "valsartan 80 MG Oral Tablet [Diovan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351762", "drug_name": "valsartan 160 MG Oral Tablet [Diovan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "351842", "drug_name": "Fenofibrate 67 MG Oral Capsule [Lofibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351859", "drug_name": "insulin, regular, human 500 UNT/ML Injectable Solution [Humulin R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351875", "drug_name": "72 HR Scopolamine 0.0139 MG/HR Transdermal System [Transderm Scop]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351898", "drug_name": "Fenofibrate 200 MG Oral Capsule [Lofibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351901", "drug_name": "Sirolimus 1 MG/ML Oral Solution [Rapamune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351909", "drug_name": "Fenofibrate 134 MG Oral Capsule [Lofibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351913", "drug_name": "ciclopirox 0.0077 MG/MG Topical Gel [Loprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351926", "drug_name": "insulin aspart, human 100 UNT/ML Injectable Solution [NovoLog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351945", "drug_name": "5 ML zoledronic acid 0.8 MG/ML Injection [Zometa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351973", "drug_name": "gabapentin 50 MG/ML Oral Solution [Neurontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351989", "drug_name": "Sirolimus 1 MG Oral Tablet [Rapamune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351991", "drug_name": "ropinirole 3 MG Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351992", "drug_name": "oxcarbazepine 60 MG/ML Oral Suspension [Trileptal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "351993", "drug_name": "Follitropin Alfa 600 UNT/ML Injectable Solution [Gonal F]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352001", "drug_name": "valsartan 320 MG Oral Tablet [Diovan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352044", "drug_name": "1 ML darbepoetin alfa 0.025 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352045", "drug_name": "1 ML darbepoetin alfa 0.04 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352046", "drug_name": "1 ML darbepoetin alfa 0.06 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352047", "drug_name": "1 ML darbepoetin alfa 0.1 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352050", "drug_name": "Tenofovir disoproxil fumarate 300 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352058", "drug_name": "frovatriptan 2.5 MG Oral Tablet [Frova]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352066", "drug_name": "bosentan 62.5 MG Oral Tablet [Tracleer]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352076", "drug_name": "1 ML paricalcitol 0.002 MG/ML Injection [Zemplar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352085", "drug_name": "Pimecrolimus 10 MG/ML Topical Cream [Elidel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352086", "drug_name": "desloratadine 5 MG Oral Tablet [Clarinex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352118", "drug_name": "Dutasteride 0.5 MG Oral Capsule [Avodart]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352119", "drug_name": "nitisinone 2 MG Oral Capsule [Orfadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352120", "drug_name": "nitisinone 5 MG Oral Capsule [Orfadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352121", "drug_name": "nitisinone 10 MG Oral Capsule [Orfadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352125", "drug_name": "pantoprazole 20 MG Delayed Release Oral Tablet [Protonix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352132", "drug_name": "Levalbuterol 0.103 MG/ML Inhalation Solution [Xopenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352143", "drug_name": "efavirenz 600 MG Oral Tablet [Sustiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352188", "drug_name": "tegaserod 6 MG Oral Tablet [Zelnorm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352199", "drug_name": "Olmesartan medoxomil 5 MG Oral Tablet [Benicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352200", "drug_name": "Olmesartan medoxomil 20 MG Oral Tablet [Benicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352201", "drug_name": "Olmesartan medoxomil 40 MG Oral Tablet [Benicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352210", "drug_name": "Mesna 400 MG Oral Tablet [Mesnex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352218", "drug_name": "voriconazole 50 MG Oral Tablet [Vfend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352219", "drug_name": "voriconazole 200 MG Oral Tablet [Vfend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352228", "drug_name": "ziprasidone 20 MG Injection [Geodon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352230", "drug_name": "Lamivudine 300 MG Oral Tablet [Epivir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352257", "drug_name": "Sodium Oxybate 500 MG/ML Oral Solution [Xyrem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352262", "drug_name": "1 ML darbepoetin alfa 0.3 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352272", "drug_name": "Escitalopram 10 MG Oral Tablet [Lexapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352273", "drug_name": "Escitalopram 20 MG Oral Tablet [Lexapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352274", "drug_name": "valsartan 40 MG Oral Tablet [Diovan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352277", "drug_name": "metaxalone 800 MG Oral Tablet [Skelaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352297", "drug_name": "1 ML peginterferon alfa-2a 0.18 MG/ML Injection [Pegasys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352304", "drug_name": "ezetimibe 10 MG Oral Tablet [Zetia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352305", "drug_name": "Oxandrolone 10 MG Oral Tablet [Oxandrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352307", "drug_name": "aripiprazole 10 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352308", "drug_name": "aripiprazole 15 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352309", "drug_name": "aripiprazole 20 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352310", "drug_name": "aripiprazole 30 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352314", "drug_name": "celecoxib 400 MG Oral Capsule [Celebrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "352317", "drug_name": "atomoxetine 10 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352318", "drug_name": "atomoxetine 18 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352319", "drug_name": "atomoxetine 25 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352320", "drug_name": "atomoxetine 40 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352321", "drug_name": "atomoxetine 60 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "352337", "drug_name": "Ribavirin 200 MG Oral Tablet [Copegus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "353538", "drug_name": "24 HR Isosorbide Mononitrate 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "358917", "drug_name": "Benzoyl Peroxide 0.05 MG/MG / Clindamycin 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359144", "drug_name": "12 HR Albuterol 4 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359145", "drug_name": "12 HR Albuterol 8 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359296", "drug_name": "calcium acetate 667 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359383", "drug_name": "24 HR Ciprofloxacin 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359385", "drug_name": "24 HR Clarithromycin 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359493", "drug_name": "eletriptan 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "359494", "drug_name": "eletriptan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "359500", "drug_name": "24 HR Etodolac 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "359697", "drug_name": "24 HR Ketoprofen 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "360110", "drug_name": "Sirolimus 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "360344", "drug_name": "24 HR Nisoldipine 40 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "360394", "drug_name": "Osmotic 24 HR Nifedipine 30 MG Extended Release Oral Tablet [Nifedical]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "360507", "drug_name": "24 HR fluvastatin 80 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "381056", "drug_name": "Isosorbide Dinitrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "387003", "drug_name": "Levetiracetam 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "388054", "drug_name": "latanoprost 0.05 MG/ML / Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "388311", "drug_name": "12 HR Carbamazepine 100 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "388517", "drug_name": "Calcitriol 0.000003 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "388525", "drug_name": "Betamethasone 0.0005 MG/MG / calcipotriene 0.00005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "389242", "drug_name": "deferiprone 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "391937", "drug_name": "Lactulose 667 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "392038", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "393245", "drug_name": "Digoxin 0.05 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "401938", "drug_name": "Miglustat 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "401953", "drug_name": "Risperidone 1 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "401954", "drug_name": "Risperidone 2 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402014", "drug_name": "Omeprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402019", "drug_name": "tadalafil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402091", "drug_name": "gefitinib 250 MG Oral Tablet [Iressa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402092", "drug_name": "Cyclosporine 0.5 MG/ML Ophthalmic Suspension [Restasis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402093", "drug_name": "Atazanavir 200 MG Oral Capsule [Reyataz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402094", "drug_name": "Atazanavir 150 MG Oral Capsule [Reyataz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402096", "drug_name": "tadalafil 10 MG Oral Tablet [Cialis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402097", "drug_name": "tadalafil 20 MG Oral Tablet [Cialis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402105", "drug_name": "eplerenone 50 MG Oral Tablet [Inspra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402106", "drug_name": "eplerenone 25 MG Oral Tablet [Inspra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402109", "drug_name": "fosamprenavir 700 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402110", "drug_name": "fosamprenavir 700 MG Oral Tablet [Lexiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402131", "drug_name": "aripiprazole 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402169", "drug_name": "zolmitriptan 5 MG/ACTUAT Nasal Spray [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402246", "drug_name": "Atazanavir 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402247", "drug_name": "Atazanavir 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402252", "drug_name": "168 HR Estradiol 0.00188 MG/HR / Levonorgestrel 0.000625 MG/HR Transdermal System [Climara Pro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "402505", "drug_name": "12 HR Carbamazepine 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402506", "drug_name": "12 HR Carbamazepine 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402695", "drug_name": "24 HR Felodipine 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402696", "drug_name": "24 HR Felodipine 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "402698", "drug_name": "24 HR Felodipine 2.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403810", "drug_name": "aprepitant 80 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403818", "drug_name": "moxifloxacin 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403825", "drug_name": "Risperidone 0.5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403840", "drug_name": "Minocycline 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403850", "drug_name": "Carbidopa 12.5 MG / entacapone 200 MG / Levodopa 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403851", "drug_name": "Carbidopa 25 MG / entacapone 200 MG / Levodopa 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403852", "drug_name": "Carbidopa 37.5 MG / entacapone 200 MG / Levodopa 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403853", "drug_name": "Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403854", "drug_name": "Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403855", "drug_name": "Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403875", "drug_name": "emtricitabine 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403878", "drug_name": "imatinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403879", "drug_name": "imatinib 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403884", "drug_name": "Levetiracetam 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403908", "drug_name": "Ciprofloxacin 3 MG/ML / Dexamethasone 1 MG/ML Otic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403914", "drug_name": "methscopolamine bromide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403921", "drug_name": "24 HR Ciprofloxacin 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403922", "drug_name": "168 HR Estradiol 0.00156 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403923", "drug_name": "168 HR Estradiol 0.0025 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "403966", "drug_name": "zonisamide 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403967", "drug_name": "zonisamide 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403969", "drug_name": "Fluoxetine 25 MG / olanzapine 6 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403970", "drug_name": "Fluoxetine 25 MG / olanzapine 12 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403971", "drug_name": "Fluoxetine 50 MG / olanzapine 12 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403972", "drug_name": "Fluoxetine 50 MG / olanzapine 6 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "403975", "drug_name": "alosetron 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404011", "drug_name": "Amlodipine 5 MG / atorvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404013", "drug_name": "Amlodipine 10 MG / atorvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404058", "drug_name": "Isotretinoin 10 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404059", "drug_name": "Isotretinoin 10 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404061", "drug_name": "Isotretinoin 20 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404062", "drug_name": "Isotretinoin 20 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404064", "drug_name": "Isotretinoin 40 MG Oral Capsule [Amnesteem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404065", "drug_name": "Isotretinoin 40 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404086", "drug_name": "Methoxsalen 10 MG/ML Topical Lotion [Oxsoralen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404406", "drug_name": "montelukast 4 MG Oral Granules [Singulair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404408", "drug_name": "Escitalopram 5 MG Oral Tablet [Lexapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404419", "drug_name": "nitazoxanide 20 MG/ML Oral Suspension [Alinia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404420", "drug_name": "Escitalopram 1 MG/ML Oral Solution [Lexapro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404432", "drug_name": "Sirolimus 2 MG Oral Tablet [Rapamune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404443", "drug_name": "eletriptan 20 MG Oral Tablet [Relpax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404444", "drug_name": "eletriptan 40 MG Oral Tablet [Relpax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404448", "drug_name": "84 HR oxybutynin 0.162 MG/HR Transdermal System [Oxytrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404449", "drug_name": "Thalidomide 100 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404450", "drug_name": "Thalidomide 200 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404457", "drug_name": "pegvisomant 10 MG Injection [Somavert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404458", "drug_name": "pegvisomant 15 MG Injection [Somavert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404459", "drug_name": "pegvisomant 20 MG Injection [Somavert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404460", "drug_name": "enfuvirtide 90 MG Injection [Fuzeon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404465", "drug_name": "aprepitant 80 MG Oral Capsule [Emend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404466", "drug_name": "aprepitant 125 MG Oral Capsule [Emend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404473", "drug_name": "moxifloxacin 5 MG/ML Ophthalmic Solution [Vigamox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404475", "drug_name": "Azathioprine 75 MG Oral Tablet [Azasan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404476", "drug_name": "Azathioprine 100 MG Oral Tablet [Azasan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404550", "drug_name": "Estrogens, Conjugated (USP) 0.45 MG Oral Tablet [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404551", "drug_name": "Carbidopa 12.5 MG / entacapone 200 MG / Levodopa 50 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404552", "drug_name": "Carbidopa 25 MG / entacapone 200 MG / Levodopa 100 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404553", "drug_name": "Carbidopa 37.5 MG / entacapone 200 MG / Levodopa 150 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404587", "drug_name": "emtricitabine 200 MG Oral Capsule [Emtriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404588", "drug_name": "imatinib 100 MG Oral Tablet [Gleevec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404589", "drug_name": "imatinib 400 MG Oral Tablet [Gleevec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404595", "drug_name": "Levetiracetam 100 MG/ML Oral Solution [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404602", "drug_name": "aripiprazole 5 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404630", "drug_name": "Ciprofloxacin 3 MG/ML / Dexamethasone 1 MG/ML Otic Suspension [Ciprodex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404636", "drug_name": "vardenafil 2.5 MG Oral Tablet [Levitra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404637", "drug_name": "vardenafil 5 MG Oral Tablet [Levitra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404638", "drug_name": "vardenafil 10 MG Oral Tablet [Levitra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404639", "drug_name": "vardenafil 20 MG Oral Tablet [Levitra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404656", "drug_name": "168 HR Estradiol 0.00156 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404657", "drug_name": "168 HR Estradiol 0.0025 MG/HR Transdermal System [Climara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404711", "drug_name": "tadalafil 5 MG Oral Tablet [Cialis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "404725", "drug_name": "zonisamide 25 MG Oral Capsule [Zonegran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "404742", "drug_name": "12 HR Carbamazepine 100 MG Extended Release Oral Capsule [Carbatrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "409823", "drug_name": "Cefixime 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "419849", "drug_name": "Cefixime 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "422410", "drug_name": "Midazolam 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "422998", "drug_name": "Salicylic Acid 60 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "429212", "drug_name": "Clozapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "429503", "drug_name": "Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "430551", "drug_name": "benznidazole 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "430902", "drug_name": "Baclofen 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "432400", "drug_name": "cinacalcet 90 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "432401", "drug_name": "cinacalcet 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "432402", "drug_name": "cinacalcet 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "433798", "drug_name": "24 HR Alprazolam 0.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "433799", "drug_name": "24 HR Alprazolam 2 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "433800", "drug_name": "24 HR Alprazolam 1 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "433801", "drug_name": "24 HR Alprazolam 3 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "465355", "drug_name": "voriconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476177", "drug_name": "Clozapine 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476179", "drug_name": "Clozapine 25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476271", "drug_name": "6-Aminocaproic Acid 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476345", "drug_name": "ezetimibe 10 MG / Simvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476349", "drug_name": "ezetimibe 10 MG / Simvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476350", "drug_name": "ezetimibe 10 MG / Simvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476351", "drug_name": "ezetimibe 10 MG / Simvastatin 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476399", "drug_name": "Carbidopa 25 MG / Levodopa 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476515", "drug_name": "Carbidopa 25 MG / Levodopa 250 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476556", "drug_name": "emtricitabine 200 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "476576", "drug_name": "cefdinir 50 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476809", "drug_name": "Mirtazapine 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "476872", "drug_name": "Nizatidine 15 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477031", "drug_name": "Salicylic Acid 60 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477367", "drug_name": "solifenacin succinate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477372", "drug_name": "solifenacin succinate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477391", "drug_name": "Levofloxacin 25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477560", "drug_name": "Fenofibrate 145 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "477562", "drug_name": "Fenofibrate 48 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483090", "drug_name": "Carbidopa 10 MG / Levodopa 100 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483438", "drug_name": "pregabalin 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483440", "drug_name": "pregabalin 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483442", "drug_name": "pregabalin 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483444", "drug_name": "pregabalin 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483446", "drug_name": "pregabalin 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483448", "drug_name": "pregabalin 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "483450", "drug_name": "pregabalin 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485020", "drug_name": "Mycophenolic Acid 180 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485023", "drug_name": "Mycophenolic Acid 360 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485413", "drug_name": "Alprazolam 0.25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485414", "drug_name": "Alprazolam 1 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485415", "drug_name": "Alprazolam 0.5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485416", "drug_name": "Alprazolam 2 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485434", "drug_name": "entecavir 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485436", "drug_name": "entecavir 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485440", "drug_name": "Eszopiclone 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485442", "drug_name": "Eszopiclone 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485465", "drug_name": "Eszopiclone 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485489", "drug_name": "Temazepam 22.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "485496", "drug_name": "aripiprazole 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "485968", "drug_name": "olanzapine 10 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "486131", "drug_name": "Benzoyl Peroxide 0.1 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "486146", "drug_name": "24 HR Nitroglycerin 0.6 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "486148", "drug_name": "24 HR Nitroglycerin 0.2 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "486152", "drug_name": "24 HR Nitroglycerin 0.4 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "486155", "drug_name": "84 HR Estradiol 0.00104 MG/HR Transdermal System [Alora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "487261", "drug_name": "Silver Nitrate 0.1 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539384", "drug_name": "Temazepam 22.5 MG Oral Capsule [Restoril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539485", "drug_name": "Ribavirin 200 MG Oral Capsule [Ribasphere]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539712", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 25 MG / Nitrofurantoin, Monohydrate 75 MG Oral Capsule [Macrobid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539741", "drug_name": "telithromycin 400 MG Oral Tablet [Ketek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539789", "drug_name": "rifaximin 200 MG Oral Tablet [XIFAXAN]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "539811", "drug_name": "Tinidazole 500 MG Oral Tablet [Tindamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539815", "drug_name": "solifenacin succinate 10 MG Oral Tablet [VESICARE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "539817", "drug_name": "solifenacin succinate 5 MG Oral Tablet [VESICARE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540181", "drug_name": "alosetron 0.5 MG Oral Tablet [Lotronex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "540281", "drug_name": "Fenofibrate 145 MG Oral Tablet [Tricor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540407", "drug_name": "Eszopiclone 1 MG Oral Tablet [Lunesta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540409", "drug_name": "Eszopiclone 2 MG Oral Tablet [Lunesta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540411", "drug_name": "Eszopiclone 3 MG Oral Tablet [Lunesta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540540", "drug_name": "6-Aminocaproic Acid 1000 MG Oral Tablet [Amicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540617", "drug_name": "nitazoxanide 500 MG Oral Tablet [Alinia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540687", "drug_name": "Doxercalciferol 0.0005 MG Oral Capsule [Hectorol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "540930", "drug_name": "Water 1000 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541070", "drug_name": "Miglustat 100 MG Oral Capsule [Zavesca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541363", "drug_name": "Amphetamine aspartate 7.5 MG / Amphetamine Sulfate 7.5 MG / Dextroamphetamine saccharate 7.5 MG / Dextroamphetamine Sulfate 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541365", "drug_name": "Amphetamine aspartate 7.5 MG / Amphetamine Sulfate 7.5 MG / Dextroamphetamine saccharate 7.5 MG / Dextroamphetamine Sulfate 7.5 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541524", "drug_name": "Methyltestosterone 10 MG Oral Tablet [Methitest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541660", "drug_name": "Paroxetine mesylate 10 MG Oral Tablet [Pexeva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541662", "drug_name": "Paroxetine mesylate 20 MG Oral Tablet [Pexeva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541664", "drug_name": "Paroxetine mesylate 30 MG Oral Tablet [Pexeva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541666", "drug_name": "Paroxetine mesylate 40 MG Oral Tablet [Pexeva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "541878", "drug_name": "Amphetamine aspartate 1.25 MG / Amphetamine Sulfate 1.25 MG / Dextroamphetamine saccharate 1.25 MG / Dextroamphetamine Sulfate 1.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541879", "drug_name": "Amphetamine aspartate 1.25 MG / Amphetamine Sulfate 1.25 MG / Dextroamphetamine saccharate 1.25 MG / Dextroamphetamine Sulfate 1.25 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541892", "drug_name": "Amphetamine aspartate 2.5 MG / Amphetamine Sulfate 2.5 MG / Dextroamphetamine saccharate 2.5 MG / Dextroamphetamine Sulfate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "541894", "drug_name": "Amphetamine aspartate 2.5 MG / Amphetamine Sulfate 2.5 MG / Dextroamphetamine saccharate 2.5 MG / Dextroamphetamine Sulfate 2.5 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "542059", "drug_name": "Didanosine 10 MG/ML Oral Solution [Videx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "542370", "drug_name": "Nelfinavir 625 MG Oral Tablet [Viracept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "542465", "drug_name": "lanthanum carbonate 500 MG Chewable Tablet [Fosrenol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "542512", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution [Istalol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "542527", "drug_name": "latanoprost 0.05 MG/ML Ophthalmic Solution [Xalatan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "542967", "drug_name": "Clorazepate Dipotassium 3.75 MG Oral Tablet [Tranxene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "542977", "drug_name": "Clozapine 100 MG Disintegrating Oral Tablet [Fazaclo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "543013", "drug_name": "Clozapine 25 MG Disintegrating Oral Tablet [Fazaclo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "543021", "drug_name": "24 HR darifenacin 15 MG Extended Release Oral Tablet [Enablex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543027", "drug_name": "24 HR darifenacin 7.5 MG Extended Release Oral Tablet [Enablex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543460", "drug_name": "ammonium lactate 120 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543484", "drug_name": "Fluocinonide 1 MG/ML Topical Cream [Vanos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "543492", "drug_name": "Hydrocortisone 10 MG/ML Rectal Cream [Procto-Pak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543546", "drug_name": "Nystatin 100000 UNT/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543666", "drug_name": "Salicylic Acid 60 MG/ML Topical Lotion [Salex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "543879", "drug_name": "Acetic Acid 0.009 MG/MG / Oxyquinoline Sulfate 0.00025 MG/MG Vaginal Gel [Relagard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544400", "drug_name": "Ribavirin 40 MG/ML Oral Solution [Rebetol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544452", "drug_name": "Lactulose 667 MG/ML Oral Solution [Constulose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544455", "drug_name": "Lactulose 667 MG/ML Oral Solution [Generlac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544518", "drug_name": "Fenofibrate 48 MG Oral Tablet [Tricor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544553", "drug_name": "Citric Acid 128 MG/ML / sodium citrate 98 MG/ML Oral Solution [Oracit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544597", "drug_name": "Potassium Iodide 1000 MG/ML Oral Solution [SSKI brand of Potassium Iodide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "544741", "drug_name": "Clindamycin 10 MG/ML Topical Foam [Evoclin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "544743", "drug_name": "ciclopirox 10 MG/ML Medicated Shampoo [Loprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545236", "drug_name": "Gentamicin 0.003 MG/MG Ophthalmic Ointment [Gentak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545243", "drug_name": "Fluorometholone 1 MG/ML Ophthalmic Suspension [FML]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545259", "drug_name": "loteprednol etabonate 5 MG/ML / Tobramycin 3 MG/ML Ophthalmic Suspension [Zylet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545276", "drug_name": "168 HR Estradiol 0.000583 MG/HR Transdermal System [Menostar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "545278", "drug_name": "24 HR Nitroglycerin 0.6 MG/HR Transdermal System [Minitran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545293", "drug_name": "Interferon Alfa-2b 10000000 UNT/ML Injectable Solution [Intron A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545353", "drug_name": "olanzapine 10 MG Injection [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "545835", "drug_name": "Leuprolide Acetate 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "546624", "drug_name": "voriconazole 40 MG/ML Oral Suspension [Vfend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "562251", "drug_name": "Amoxicillin 250 MG / Clavulanate 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "562508", "drug_name": "Amoxicillin 875 MG / Clavulanate 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "562524", "drug_name": "12 HR Acetazolamide 500 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "562704", "drug_name": "ropinirole 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577033", "drug_name": "sildenafil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "577057", "drug_name": "72 HR Fentanyl 0.012 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "577127", "drug_name": "pregabalin 225 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577208", "drug_name": "Omega-3 Acid Ethyl Esters (USP) 1000 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577315", "drug_name": "paricalcitol 0.001 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577317", "drug_name": "paricalcitol 0.002 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577324", "drug_name": "paricalcitol 0.004 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577348", "drug_name": "ramelteon 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577785", "drug_name": "candesartan cilexetil 4 MG Oral Tablet [Atacand]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577787", "drug_name": "candesartan cilexetil 8 MG Oral Tablet [Atacand]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "577957", "drug_name": "Amphetamine aspartate 3.75 MG / Amphetamine Sulfate 3.75 MG / Dextroamphetamine saccharate 3.75 MG / Dextroamphetamine Sulfate 3.75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "577960", "drug_name": "Amphetamine aspartate 3.75 MG / Amphetamine Sulfate 3.75 MG / Dextroamphetamine saccharate 3.75 MG / Dextroamphetamine Sulfate 3.75 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "577961", "drug_name": "Amphetamine aspartate 5 MG / Amphetamine Sulfate 5 MG / Dextroamphetamine saccharate 5 MG / Dextroamphetamine Sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "577962", "drug_name": "Amphetamine aspartate 5 MG / Amphetamine Sulfate 5 MG / Dextroamphetamine saccharate 5 MG / Dextroamphetamine Sulfate 5 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "578457", "drug_name": "entecavir 0.5 MG Oral Tablet [Baraclude]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "578459", "drug_name": "entecavir 1 MG Oral Tablet [Baraclude]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "579148", "drug_name": "Galantamine 12 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "580261", "drug_name": "tiotropium 0.018 MG Inhalation Powder [Spiriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "580267", "drug_name": "tizanidine 6 MG Oral Capsule [Zanaflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "580286", "drug_name": "mesalamine 500 MG Extended Release Oral Capsule [Pentasa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "580294", "drug_name": "sertaconazole 20 MG/ML Topical Cream [Ertaczo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "581549", "drug_name": "Estradiol 0.0006 MG/MG Topical Gel [Estrogel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "581574", "drug_name": "Cefixime 20 MG/ML Oral Suspension [Suprax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "581583", "drug_name": "Cefuroxime 25 MG/ML Oral Suspension [Ceftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "581584", "drug_name": "Cefuroxime 50 MG/ML Oral Suspension [Ceftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "581614", "drug_name": "linezolid 20 MG/ML Oral Suspension [Zyvox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "581645", "drug_name": "sildenafil 20 MG Oral Tablet [Revatio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "582299", "drug_name": "6-Aminocaproic Acid 250 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "582328", "drug_name": "Sumatriptan 20 MG/ACTUAT Nasal Spray [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "582330", "drug_name": "Sumatriptan 5 MG/ACTUAT Nasal Spray [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "582595", "drug_name": "Iloprost 0.01 MG/ML Inhalation Solution [Ventavis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "582926", "drug_name": "podofilox 5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "582929", "drug_name": "podofilox 5 MG/ML Topical Solution [Condylox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "582971", "drug_name": "Somatropin 12 MG Cartridge [Humatrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "582976", "drug_name": "Somatropin 24 MG Cartridge [Humatrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "582984", "drug_name": "Somatropin 8.8 MG/ML Injectable Solution [Zorbtive]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583096", "drug_name": "Fenofibrate 160 MG Oral Tablet [Triglide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583165", "drug_name": "tizanidine 2 MG Oral Capsule [Zanaflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583170", "drug_name": "Salsalate 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583211", "drug_name": "tizanidine 4 MG Oral Capsule [Zanaflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583257", "drug_name": "mesalamine 1000 MG Rectal Suppository [Canasa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583453", "drug_name": "20 ML ziconotide acetate 0.025 MG/ML Injection [Prialt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583482", "drug_name": "Azithromycin 33.3 MG/ML Extended Release Suspension [Zmax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "583490", "drug_name": "72 HR Fentanyl 0.012 MG/HR Transdermal System [Duragesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596843", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596918", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule [Prevacid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596926", "drug_name": "duloxetine 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596928", "drug_name": "duloxetine 20 MG Delayed Release Oral Capsule [Cymbalta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596930", "drug_name": "duloxetine 30 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596932", "drug_name": "duloxetine 30 MG Delayed Release Oral Capsule [Cymbalta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "596934", "drug_name": "duloxetine 60 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597768", "drug_name": "deferasirox 125 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597770", "drug_name": "deferasirox 250 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597772", "drug_name": "deferasirox 500 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597850", "drug_name": "anagrelide 0.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597852", "drug_name": "anagrelide 1 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597857", "drug_name": "anagrelide 0.5 MG Oral Capsule [Agrylin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "597967", "drug_name": "Amlodipine 10 MG / atorvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597971", "drug_name": "Amlodipine 2.5 MG / atorvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597974", "drug_name": "Amlodipine 2.5 MG / atorvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597977", "drug_name": "Amlodipine 5 MG / atorvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597980", "drug_name": "Amlodipine 5 MG / atorvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597984", "drug_name": "Amlodipine 5 MG / atorvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597987", "drug_name": "Amlodipine 10 MG / atorvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597990", "drug_name": "Amlodipine 10 MG / atorvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "597993", "drug_name": "Amlodipine 2.5 MG / atorvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "598006", "drug_name": "Erythromycin 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "598014", "drug_name": "Interferon Alfa-n3 5000000 UNT/ML Injectable Solution [Alferon N]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "598025", "drug_name": "Amoxicillin 250 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "598032", "drug_name": "Fluoxetine 90 MG Delayed Release Oral Capsule [Prozac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "602393", "drug_name": "abacavir 600 MG / Lamivudine 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "602395", "drug_name": "abacavir 600 MG / Lamivudine 300 MG Oral Tablet [Epzicom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "602427", "drug_name": "Clindamycin 20 MG/ML Vaginal Cream [Clindesse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "602734", "drug_name": "Galantamine 12 MG Oral Tablet [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "602736", "drug_name": "Galantamine 4 MG Oral Tablet [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "602737", "drug_name": "Galantamine 8 MG Oral Tablet [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "602855", "drug_name": "telithromycin 300 MG Oral Tablet [Ketek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "602964", "drug_name": "aripiprazole 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "603103", "drug_name": "Naproxen 375 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603112", "drug_name": "lanthanum carbonate 1000 MG Chewable Tablet [Fosrenol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603122", "drug_name": "lanthanum carbonate 750 MG Chewable Tablet [Fosrenol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603162", "drug_name": "ramelteon 8 MG Oral Tablet [Rozerem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603203", "drug_name": "erlotinib 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "603206", "drug_name": "erlotinib 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "603208", "drug_name": "erlotinib 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "603281", "drug_name": "potassium citrate 10 MEQ Extended Release Oral Tablet [Urocit-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603282", "drug_name": "potassium citrate 5 MEQ Extended Release Oral Tablet [Urocit-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603378", "drug_name": "tipranavir 250 MG Oral Capsule [Aptivus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "603834", "drug_name": "Fenofibrate 160 MG Oral Tablet [Lofibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603836", "drug_name": "Fenofibrate 54 MG Oral Tablet [Lofibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603844", "drug_name": "meloxicam 1.5 MG/ML Oral Suspension [Mobic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "603978", "drug_name": "nepafenac 1 MG/ML Ophthalmic Suspension [Nevanac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "604379", "drug_name": "0.5 ML follitropin beta 150 UNT/ML Injection [Follistim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "605730", "drug_name": "Metronidazole 0.01 MG/MG Topical Gel [MetroGel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "606726", "drug_name": "Esomeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "606728", "drug_name": "Esomeprazole 20 MG Delayed Release Oral Capsule [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "606730", "drug_name": "Esomeprazole 40 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "606731", "drug_name": "Esomeprazole 40 MG Delayed Release Oral Capsule [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "606854", "drug_name": "paricalcitol 0.001 MG Oral Capsule [Zemplar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "606859", "drug_name": "paricalcitol 0.002 MG Oral Capsule [Zemplar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "606947", "drug_name": "Acetaminophen 325 MG / dichloralphenazone 100 MG / isometheptene 65 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607018", "drug_name": "pregabalin 100 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607020", "drug_name": "pregabalin 150 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607022", "drug_name": "pregabalin 200 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607024", "drug_name": "pregabalin 225 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607026", "drug_name": "pregabalin 25 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607028", "drug_name": "pregabalin 300 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607033", "drug_name": "pregabalin 50 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607038", "drug_name": "pregabalin 75 MG Oral Capsule [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607044", "drug_name": "Omega-3 Acid Ethyl Esters (USP) 1000 MG Oral Capsule [Lovaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607295", "drug_name": "Dapsone 0.05 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "607579", "drug_name": "entecavir 0.05 MG/ML Oral Solution [Baraclude]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "608139", "drug_name": "atomoxetine 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "608143", "drug_name": "atomoxetine 80 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "608328", "drug_name": "rasagiline 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "608793", "drug_name": "Naproxen 375 MG Delayed Release Oral Tablet [Naprosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "608934", "drug_name": "Metronidazole 0.0075 MG/MG Vaginal Gel [Vandazole]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "615172", "drug_name": "aripiprazole 2 MG Oral Tablet [Abilify]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "615186", "drug_name": "duloxetine 60 MG Delayed Release Oral Capsule [Cymbalta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "615882", "drug_name": "mecasermin 10 MG/ML Injectable Solution [Increlex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "615979", "drug_name": "sorafenib 200 MG Oral Tablet [Nexavar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616114", "drug_name": "lenalidomide 10 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616116", "drug_name": "lenalidomide 5 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616129", "drug_name": "Ribavirin 200 MG Oral Tablet [Ribasphere]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616131", "drug_name": "Ribavirin 400 MG Oral Tablet [Ribasphere]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616133", "drug_name": "Ribavirin 600 MG Oral Tablet [Ribasphere]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616148", "drug_name": "emtricitabine 10 MG/ML Oral Solution [Emtriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616159", "drug_name": "deferasirox 125 MG Tablet for Oral Suspension [Exjade]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616161", "drug_name": "deferasirox 250 MG Tablet for Oral Suspension [Exjade]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616163", "drug_name": "deferasirox 500 MG Tablet for Oral Suspension [Exjade]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616238", "drug_name": "insulin detemir 100 UNT/ML Injectable Solution [Levemir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616283", "drug_name": "sunitinib 12.5 MG Oral Capsule [Sutent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616287", "drug_name": "sunitinib 25 MG Oral Capsule [Sutent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616292", "drug_name": "sunitinib 50 MG Oral Capsule [Sutent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616435", "drug_name": "mycophenolate mofetil 500 MG Oral Tablet [Cellcept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616444", "drug_name": "mycophenolate mofetil 200 MG/ML Oral Suspension [Cellcept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616447", "drug_name": "mycophenolate mofetil 250 MG Oral Capsule [Cellcept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616449", "drug_name": "Mycophenolic Acid 360 MG Delayed Release Oral Tablet [Myfortic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616450", "drug_name": "Mycophenolic Acid 180 MG Delayed Release Oral Tablet [Myfortic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616483", "drug_name": "quetiapine 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616485", "drug_name": "quetiapine 400 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616487", "drug_name": "quetiapine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616489", "drug_name": "quetiapine 50 MG Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616541", "drug_name": "Omeprazole 40 MG / Sodium Bicarbonate 1100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "616698", "drug_name": "Risperidone 3 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616705", "drug_name": "Risperidone 4 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616749", "drug_name": "12 HR ranolazine 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616817", "drug_name": "Budesonide 0.25 MG/ML Inhalation Suspension [Pulmicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616819", "drug_name": "Budesonide 0.5 MG/ML Inhalation Suspension [Pulmicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616830", "drug_name": "Budesonide 0.125 MG/ML Inhalation Suspension [Pulmicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616852", "drug_name": "Fenofibrate 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "616853", "drug_name": "Fenofibrate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617296", "drug_name": "Amoxicillin 500 MG / Clavulanate 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617309", "drug_name": "Amoxicillin 200 MG / Clavulanate 28.5 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617310", "drug_name": "atorvastatin 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617311", "drug_name": "atorvastatin 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617312", "drug_name": "atorvastatin 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617314", "drug_name": "atorvastatin 10 MG Oral Tablet [Lipitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617316", "drug_name": "Amoxicillin 400 MG / Clavulanate 57 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617318", "drug_name": "atorvastatin 20 MG Oral Tablet [Lipitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617320", "drug_name": "atorvastatin 40 MG Oral Tablet [Lipitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617322", "drug_name": "Amoxicillin 50 MG/ML / Clavulanate 12.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617333", "drug_name": "Amoxicillin 25 MG/ML / Clavulanate 6.25 MG/ML Oral Suspension [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617339", "drug_name": "Amoxicillin 50 MG/ML / Clavulanate 12.5 MG/ML Oral Suspension [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617423", "drug_name": "Amoxicillin 40 MG/ML / Clavulanate 5.7 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617430", "drug_name": "Amoxicillin 80 MG/ML / Clavulanate 11.4 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617624", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste [Fluoridex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617768", "drug_name": "lubiprostone 0.024 MG Oral Capsule [Amitiza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617945", "drug_name": "atomoxetine 100 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617947", "drug_name": "atomoxetine 80 MG Oral Capsule [Strattera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "617993", "drug_name": "Amoxicillin 120 MG/ML / Clavulanate 8.58 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "617995", "drug_name": "12 HR Amoxicillin 1000 MG / Clavulanate 62.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "618028", "drug_name": "Amoxicillin 120 MG/ML / Clavulanate 8.58 MG/ML Oral Suspension [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "618552", "drug_name": "Meclofenamate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "618557", "drug_name": "Meclofenamate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "628953", "drug_name": "Potassium Chloride 10 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "628958", "drug_name": "Potassium Chloride 10 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "629695", "drug_name": "24 HR Minocycline 135 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "629697", "drug_name": "24 HR Minocycline 45 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "629699", "drug_name": "24 HR Minocycline 90 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630194", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste [Prevident]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630196", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste [Denta 5000 Plus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630208", "drug_name": "Albuterol 0.83 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630726", "drug_name": "synthetic conjugated estrogens, B 0.625 MG Oral Tablet [Enjuvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630729", "drug_name": "synthetic conjugated estrogens, B 1.25 MG Oral Tablet [Enjuvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630807", "drug_name": "Levetiracetam 1000 MG Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630890", "drug_name": "Risperidone 3 MG Disintegrating Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630974", "drug_name": "Risperidone 4 MG Disintegrating Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "630981", "drug_name": "Polyvinyl Alcohol 27 MG/ML / Povidone 20 MG/ML Ophthalmic Solution [Freshkote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "636042", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "636045", "drug_name": "Hydrochlorothiazide 25 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "636141", "drug_name": "sodium phosphate 1500 MG Oral Tablet [OsmoPrep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "636664", "drug_name": "rasagiline 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "636794", "drug_name": "12 HR Disopyramide 150 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637175", "drug_name": "Cephalexin 750 MG Oral Capsule [Keflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637185", "drug_name": "rasagiline 1 MG Oral Tablet [Azilect]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637188", "drug_name": "varenicline 0.5 MG Oral Tablet [Chantix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637190", "drug_name": "varenicline 1 MG Oral Tablet [Chantix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637218", "drug_name": "rasagiline 0.5 MG Oral Tablet [Azilect]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637365", "drug_name": "potassium nitrate 0.05 MG/MG / Sodium Fluoride 0.011 MG/MG Toothpaste", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "637562", "drug_name": "gemifloxacin 320 MG Oral Tablet [Factive]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "639539", "drug_name": "candesartan cilexetil 16 MG Oral Tablet [Atacand]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "639543", "drug_name": "candesartan cilexetil 32 MG Oral Tablet [Atacand]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "639566", "drug_name": "Vitamin B6 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "639888", "drug_name": "emtricitabine 200 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Truvada]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643019", "drug_name": "aripiprazole 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643022", "drug_name": "aripiprazole 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643066", "drug_name": "efavirenz 600 MG / emtricitabine 200 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643070", "drug_name": "efavirenz 600 MG / emtricitabine 200 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Atripla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643123", "drug_name": "prednisolone 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643125", "drug_name": "prednisolone 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643127", "drug_name": "prednisolone 30 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643173", "drug_name": "dasatinib 20 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643175", "drug_name": "dasatinib 50 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643177", "drug_name": "dasatinib 70 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643488", "drug_name": "Isotretinoin 30 MG Oral Capsule [Claravis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "643714", "drug_name": "lenalidomide 15 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643722", "drug_name": "lenalidomide 25 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "643783", "drug_name": "ferumoxsil 0.175 MG/ML Oral Suspension [Gastromark]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "644278", "drug_name": "aprepitant 40 MG Oral Capsule [Emend]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "644304", "drug_name": "Tamoxifen 2 MG/ML Oral Solution [Soltamox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "645037", "drug_name": "Risperidone 0.25 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "645669", "drug_name": "Tretinoin 0.25 MG/ML Topical Cream [Tretin X]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "645671", "drug_name": "Tretinoin 1 MG/ML Topical Cream [Tretin X]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "645884", "drug_name": "Somatropin 5 MG/ML Injectable Solution [Omnitrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "646344", "drug_name": "Omeprazole 20 MG / Sodium Bicarbonate 1100 MG Oral Capsule [Zegerid Reformulated Aug 2006]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "646352", "drug_name": "Omeprazole 40 MG / Sodium Bicarbonate 1100 MG Oral Capsule [Zegerid Reformulated Aug 2006]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "647127", "drug_name": "prednisolone 15 MG Disintegrating Oral Tablet [Orapred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "647237", "drug_name": "glimepiride 2 MG / pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "647239", "drug_name": "glimepiride 4 MG / pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "647555", "drug_name": "Fluoxetine 10 MG Oral Tablet [Sarafem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "647556", "drug_name": "Fluoxetine 20 MG Oral Tablet [Sarafem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "656137", "drug_name": "cinacalcet 30 MG Oral Tablet [Sensipar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "656659", "drug_name": "bosentan 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "656660", "drug_name": "bosentan 125 MG Oral Tablet [Tracleer]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "656882", "drug_name": "Tretinoin 0.5 MG/ML Topical Cream [Tretin X]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "664741", "drug_name": "Atazanavir 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "664743", "drug_name": "Atazanavir 300 MG Oral Capsule [Reyataz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "664961", "drug_name": "Ketoconazole 0.02 MG/MG Topical Gel [Xolegel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "665019", "drug_name": "posaconazole 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "665022", "drug_name": "posaconazole 40 MG/ML Oral Suspension [Noxafil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "665036", "drug_name": "sitagliptin 100 MG Oral Tablet [Januvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "665040", "drug_name": "sitagliptin 25 MG Oral Tablet [Januvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "665044", "drug_name": "sitagliptin 50 MG Oral Tablet [Januvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "667904", "drug_name": "Salicylic Acid 60 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "668363", "drug_name": "Fentanyl 0.1 MG Buccal Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668364", "drug_name": "Fentanyl 0.2 MG Buccal Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668365", "drug_name": "Fentanyl 0.4 MG Buccal Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668366", "drug_name": "Fentanyl 0.6 MG Buccal Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668367", "drug_name": "Fentanyl 0.8 MG Buccal Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668606", "drug_name": "Vorinostat 100 MG Oral Capsule [Zolinza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668622", "drug_name": "Fentanyl 0.1 MG Buccal Tablet [Fentora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668624", "drug_name": "Fentanyl 0.2 MG Buccal Tablet [Fentora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668626", "drug_name": "Fentanyl 0.4 MG Buccal Tablet [Fentora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668628", "drug_name": "Fentanyl 0.6 MG Buccal Tablet [Fentora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668630", "drug_name": "Fentanyl 0.8 MG Buccal Tablet [Fentora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "668658", "drug_name": "prednisolone 10 MG Disintegrating Oral Tablet [Orapred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "668660", "drug_name": "prednisolone 30 MG Disintegrating Oral Tablet [Orapred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "668691", "drug_name": "telbivudine 600 MG Oral Tablet [Tyzeka]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "669081", "drug_name": "Desonide 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "669519", "drug_name": "Clotrimazole 20 MG/ML Vaginal Cream [Gyne-Lotrimin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "669750", "drug_name": "Desonide 0.5 MG/ML Topical Foam [Verdeso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "670031", "drug_name": "Potassium Chloride 10 MEQ Extended Release Oral Tablet [K-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "670640", "drug_name": "Timolol 2.5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "670646", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672149", "drug_name": "lapatinib 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "672152", "drug_name": "lapatinib 250 MG Oral Tablet [Tykerb]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "672567", "drug_name": "24 HR paliperidone 3 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "672569", "drug_name": "24 HR paliperidone 6 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "672571", "drug_name": "24 HR paliperidone 9 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "672605", "drug_name": "Urea 300 MG/ML Topical Foam [Kerafoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672908", "drug_name": "12 HR Carbamazepine 100 MG Extended Release Oral Capsule [Equetro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672909", "drug_name": "12 HR Carbamazepine 300 MG Extended Release Oral Capsule [Equetro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672910", "drug_name": "12 HR Carbamazepine 200 MG Extended Release Oral Capsule [Equetro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672916", "drug_name": "24 HR Nifedipine 30 MG Extended Release Oral Tablet [Adalat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672917", "drug_name": "24 HR Nifedipine 60 MG Extended Release Oral Tablet [Adalat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "672918", "drug_name": "24 HR Nifedipine 90 MG Extended Release Oral Tablet [Adalat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686355", "drug_name": "erythromycin stearate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686379", "drug_name": "celecoxib 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686381", "drug_name": "celecoxib 50 MG Oral Capsule [Celebrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686400", "drug_name": "Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686402", "drug_name": "Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension [EryPed]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686405", "drug_name": "Erythromycin Ethylsuccinate 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686418", "drug_name": "Erythromycin Ethylsuccinate 80 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686420", "drug_name": "Erythromycin Ethylsuccinate 80 MG/ML Oral Suspension [EryPed]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686429", "drug_name": "mesalamine 1200 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686433", "drug_name": "mesalamine 1200 MG Delayed Release Oral Tablet [Lialda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686441", "drug_name": "24 HR paliperidone 3 MG Extended Release Oral Tablet [Invega]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "686443", "drug_name": "24 HR paliperidone 6 MG Extended Release Oral Tablet [Invega]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "686445", "drug_name": "24 HR paliperidone 9 MG Extended Release Oral Tablet [Invega]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "686924", "drug_name": "carvedilol 3.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "686926", "drug_name": "carvedilol 3.125 MG Oral Tablet [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687022", "drug_name": "24 HR Alprazolam 3 MG Extended Release Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687023", "drug_name": "24 HR Alprazolam 2 MG Extended Release Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687024", "drug_name": "24 HR Alprazolam 1 MG Extended Release Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687025", "drug_name": "24 HR Alprazolam 0.5 MG Extended Release Oral Tablet [Xanax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687043", "drug_name": "Amphetamine aspartate 3.125 MG / Amphetamine Sulfate 3.125 MG / Dextroamphetamine saccharate 3.125 MG / Dextroamphetamine Sulfate 3.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "687045", "drug_name": "Amphetamine aspartate 3.125 MG / Amphetamine Sulfate 3.125 MG / Dextroamphetamine saccharate 3.125 MG / Dextroamphetamine Sulfate 3.125 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "687048", "drug_name": "24 HR fluvastatin 80 MG Extended Release Oral Tablet [Lescol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "687059", "drug_name": "cadexomer iodine 0.009 MG/MG Topical Gel [Iodosorb]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687211", "drug_name": "Metronidazole 375 MG Oral Capsule [Flagyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "687443", "drug_name": "Lidocaine 70 MG/ML / Tetracaine 70 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "688242", "drug_name": "Estrogens, Conjugated (USP) 0.625 MG/ML Vaginal Cream [Premarin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "688596", "drug_name": "salmon calcitonin 200 UNT/ACTUAT Nasal Spray [Fortical]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "688704", "drug_name": "Bacitracin 0.4 UNT/MG / Hydrocortisone 0.01 MG/MG / Neomycin 0.0035 MG/MG / Polymyxin B 5 UNT/MG Topical Ointment [Cortisporin Ointment]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "688714", "drug_name": "Guaifenesin 20 MG/ML / Phenylephrine 1.5 MG/ML Oral Solution [Donatussin Drops]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "692576", "drug_name": "Esomeprazole 20 MG Granules for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "692578", "drug_name": "Esomeprazole 40 MG Granules for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "692688", "drug_name": "Fluoxymesterone 10 MG Oral Tablet [Androxy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "692757", "drug_name": "Desonide 0.0005 MG/MG Topical Gel [Desonate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "695935", "drug_name": "arformoterol 0.0075 MG/ML Inhalation Solution [Brovana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "700410", "drug_name": "Doxycycline Monohydrate 75 MG Oral Capsule [Monodox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "700418", "drug_name": "Thalidomide 150 MG Oral Capsule [Thalomid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "700883", "drug_name": "temozolomide 140 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "700885", "drug_name": "temozolomide 180 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "701305", "drug_name": "Tretinoin 0.00025 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "701858", "drug_name": "Dapsone 0.05 MG/MG Topical Gel [Aczone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702055", "drug_name": "Fenofibrate 150 MG Oral Capsule [Lipofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702169", "drug_name": "Fenofibrate 50 MG Oral Capsule [Lipofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702220", "drug_name": "dexchlorpheniramine 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702296", "drug_name": "Doxycycline Calcium 10 MG/ML Oral Suspension [Vibramycin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702313", "drug_name": "Silver Nitrate 100 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "702519", "drug_name": "Phenobarbital 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "704858", "drug_name": "retapamulin 0.01 MG/MG Topical Ointment [Altabax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705008", "drug_name": "Cefixime 40 MG/ML Oral Suspension [Suprax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705610", "drug_name": "Ranitidine 15 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705617", "drug_name": "temozolomide 140 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705619", "drug_name": "temozolomide 180 MG Oral Capsule [Temodar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705919", "drug_name": "Estrogens, Esterified (USP) 1.25 MG / Methyltestosterone 2.5 MG Oral Tablet [Covaryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "705921", "drug_name": "Estrogens, Esterified (USP) 0.625 MG / Methyltestosterone 1.25 MG Oral Tablet [Covaryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706467", "drug_name": "Estradiol 0.0006 MG/MG Topical Gel [Elestrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706546", "drug_name": "prednicarbate 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706547", "drug_name": "prednicarbate 0.001 MG/MG Topical Ointment [Dermatop]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706548", "drug_name": "selenium sulfide 22.5 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706872", "drug_name": "Azithromycin 10 MG/ML Ophthalmic Solution [AzaSite]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706958", "drug_name": "cinacalcet 60 MG Oral Tablet [Sensipar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "706960", "drug_name": "cinacalcet 90 MG Oral Tablet [Sensipar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "721773", "drug_name": "Clozapine 12.5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721775", "drug_name": "Clozapine 12.5 MG Disintegrating Oral Tablet [Fazaclo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721787", "drug_name": "Fluoxetine 25 MG / olanzapine 3 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "721791", "drug_name": "24 HR quetiapine 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721793", "drug_name": "24 HR quetiapine 200 MG Extended Release Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721794", "drug_name": "24 HR quetiapine 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721795", "drug_name": "24 HR quetiapine 300 MG Extended Release Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721796", "drug_name": "24 HR quetiapine 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "721797", "drug_name": "24 HR quetiapine 400 MG Extended Release Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722113", "drug_name": "adapalene 0.003 MG/MG Topical Gel [Differin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "722116", "drug_name": "ambrisentan 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722120", "drug_name": "ambrisentan 10 MG Oral Tablet [Letairis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722122", "drug_name": "ambrisentan 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722124", "drug_name": "ambrisentan 5 MG Oral Tablet [Letairis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722126", "drug_name": "Amlodipine 10 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722131", "drug_name": "Amlodipine 10 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722134", "drug_name": "Amlodipine 5 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722137", "drug_name": "Amlodipine 5 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "722256", "drug_name": "24 HR Rotigotine 0.0833 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "723526", "drug_name": "Estradiol 0.001 MG/MG Topical Gel [Divigel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "723827", "drug_name": "fosamprenavir 50 MG/ML Oral Suspension [Lexiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724142", "drug_name": "24 HR Rotigotine 0.167 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724154", "drug_name": "Sulfasalazine 500 MG Delayed Release Oral Tablet [Azulfidine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724156", "drug_name": "24 HR Rotigotine 0.25 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724598", "drug_name": "Carbidopa 25 MG / Levodopa 100 MG Oral Tablet [Sinemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724602", "drug_name": "Carbidopa 25 MG / Levodopa 250 MG Oral Tablet [Sinemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724606", "drug_name": "Carbidopa 10 MG / Levodopa 100 MG Oral Tablet [Sinemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724859", "drug_name": "armodafinil 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724861", "drug_name": "armodafinil 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724863", "drug_name": "armodafinil 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "724879", "drug_name": "Amlodipine 10 MG / valsartan 160 MG Oral Tablet [Exforge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724887", "drug_name": "Amlodipine 10 MG / valsartan 320 MG Oral Tablet [Exforge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724891", "drug_name": "Amlodipine 5 MG / valsartan 160 MG Oral Tablet [Exforge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "724895", "drug_name": "Amlodipine 5 MG / valsartan 320 MG Oral Tablet [Exforge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725064", "drug_name": "Fluoxetine 25 MG / olanzapine 6 MG Oral Capsule [Symbyax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725068", "drug_name": "Fluoxetine 50 MG / olanzapine 12 MG Oral Capsule [Symbyax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725072", "drug_name": "Fluoxetine 50 MG / olanzapine 6 MG Oral Capsule [Symbyax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725076", "drug_name": "Fluoxetine 25 MG / olanzapine 12 MG Oral Capsule [Symbyax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725080", "drug_name": "Fluoxetine 25 MG / olanzapine 3 MG Oral Capsule [Symbyax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "725098", "drug_name": "Progesterone 100 MG Vaginal Insert [Endometrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "725105", "drug_name": "24 HR rivastigmine 0.396 MG/HR Transdermal System [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "727316", "drug_name": "NDA019430 0.3 ML Epinephrine 0.5 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727345", "drug_name": "0.3 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727347", "drug_name": "NDA019430 0.3 ML Epinephrine 1 MG/ML Auto-Injector [Epipen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727386", "drug_name": "NDA019430 0.3 ML Epinephrine 0.5 MG/ML Auto-Injector [Epipen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727410", "drug_name": "0.15 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727507", "drug_name": "0.5 ML choriogonadotropin alfa 0.5 MG/ML Prefilled Syringe [Ovidrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "727537", "drug_name": "0.5 ML Filgrastim 0.6 MG/ML Prefilled Syringe [Neupogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "727542", "drug_name": "0.6 ML pegfilgrastim 10 MG/ML Prefilled Syringe [Neulasta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "727545", "drug_name": "0.8 ML Filgrastim 0.6 MG/ML Prefilled Syringe [Neupogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "727705", "drug_name": "0.8 ML adalimumab 50 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727714", "drug_name": "0.67 ML anakinra 149 MG/ML Prefilled Syringe [Kineret]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "727816", "drug_name": "0.5 ML Interferon beta-1a 0.06 MG/ML Prefilled Syringe [Avonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "728109", "drug_name": "Oseltamivir 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "728111", "drug_name": "Oseltamivir 30 MG Oral Capsule [Tamiflu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "728113", "drug_name": "Oseltamivir 45 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "728115", "drug_name": "Oseltamivir 45 MG Oral Capsule [Tamiflu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "728122", "drug_name": "Estradiol 1.53 MG/ACTUAT Topical Spray [Evamist]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "728126", "drug_name": "Lidocaine 70 MG/ML / Tetracaine 70 MG/ML Topical Cream [Pliaglis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "728231", "drug_name": "12 HR ranolazine 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "728546", "drug_name": "Urea 400 MG/ML Topical Foam [Hydro 40]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "728550", "drug_name": "Ketoconazole 20 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "729201", "drug_name": "maraviroc 150 MG Oral Tablet [Selzentry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "729203", "drug_name": "maraviroc 300 MG Oral Tablet [Selzentry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "729234", "drug_name": "Somatropin 6 MG Cartridge [Humatrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "729768", "drug_name": "Ketoconazole 20 MG/ML Topical Foam [Extina]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "729929", "drug_name": "24 HR venlafaxine 75 MG Extended Release Oral Capsule [Effexor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "729931", "drug_name": "24 HR venlafaxine 150 MG Extended Release Oral Capsule [Effexor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "729932", "drug_name": "24 HR venlafaxine 37.5 MG Extended Release Oral Capsule [Effexor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "730046", "drug_name": "0.5 ML darbepoetin alfa 0.2 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "730861", "drug_name": "Amlodipine 10 MG / Olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "730866", "drug_name": "Amlodipine 10 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "730869", "drug_name": "Amlodipine 5 MG / Olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "730872", "drug_name": "Amlodipine 5 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "730880", "drug_name": "synthetic conjugated estrogens, B 0.9 MG Oral Tablet [Enjuvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "730918", "drug_name": "Carisoprodol 250 MG Oral Tablet [Soma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "730988", "drug_name": "Carbidopa 50 MG / entacapone 200 MG / Levodopa 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "730992", "drug_name": "Carbidopa 50 MG / entacapone 200 MG / Levodopa 200 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731227", "drug_name": "0.4 ML darbepoetin alfa 0.1 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731229", "drug_name": "0.6 ML darbepoetin alfa 0.5 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731231", "drug_name": "0.3 ML darbepoetin alfa 0.5 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731235", "drug_name": "0.4 ML darbepoetin alfa 0.5 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731241", "drug_name": "1 ML darbepoetin alfa 0.5 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731245", "drug_name": "0.42 ML darbepoetin alfa 0.06 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731250", "drug_name": "0.3 ML darbepoetin alfa 0.2 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731281", "drug_name": "Insulin Lispro 50 UNT/ML / insulin lispro protamine, human 50 UNT/ML Injectable Suspension [Humalog Mix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731457", "drug_name": "glimepiride 4 MG / pioglitazone 30 MG Oral Tablet [Duetact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731463", "drug_name": "glimepiride 2 MG / pioglitazone 30 MG Oral Tablet [Duetact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "731526", "drug_name": "Methyltestosterone 10 MG Oral Capsule [Android]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "744624", "drug_name": "Amlodipine 10 MG / Olmesartan medoxomil 20 MG Oral Tablet [Azor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "744628", "drug_name": "Amlodipine 10 MG / Olmesartan medoxomil 40 MG Oral Tablet [Azor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "744632", "drug_name": "Amlodipine 5 MG / Olmesartan medoxomil 20 MG Oral Tablet [Azor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "744636", "drug_name": "Amlodipine 5 MG / Olmesartan medoxomil 40 MG Oral Tablet [Azor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "744846", "drug_name": "raltegravir 400 MG Oral Tablet [ISENTRESS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "745679", "drug_name": "200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "745752", "drug_name": "NDA021457 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "745768", "drug_name": "selenium sulfide 22.5 MG/ML Topical Foam [Tersi Foam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "745791", "drug_name": "200 ACTUAT Levalbuterol 0.045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746023", "drug_name": "Atenolol 100 MG / Chlorthalidone 25 MG Oral Tablet [Tenoretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "746030", "drug_name": "Atenolol 50 MG / Chlorthalidone 25 MG Oral Tablet [Tenoretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "746199", "drug_name": "120 ACTUAT mometasone furoate 0.05 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "746201", "drug_name": "120 ACTUAT mometasone furoate 0.05 MG/ACTUAT Nasal Inhaler [Nasonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "746466", "drug_name": "200 ACTUAT Levalbuterol 0.045 MG/ACTUAT Metered Dose Inhaler [Xopenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746609", "drug_name": "nilotinib 200 MG Oral Capsule [Tasigna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746763", "drug_name": "NDA020503 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [Proventil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746804", "drug_name": "120 ACTUAT mometasone furoate 0.22 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746811", "drug_name": "14 ACTUAT mometasone furoate 0.22 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746813", "drug_name": "30 ACTUAT mometasone furoate 0.22 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746815", "drug_name": "60 ACTUAT mometasone furoate 0.22 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "746821", "drug_name": "120 ACTUAT Budesonide 0.032 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "746823", "drug_name": "120 ACTUAT Budesonide 0.032 MG/ACTUAT Nasal Inhaler [Rhinocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748738", "drug_name": "Topotecan 0.25 MG Oral Capsule [Hycamtin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748740", "drug_name": "Topotecan 1 MG Oral Capsule [Hycamtin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748743", "drug_name": "Clindamycin 15 MG/ML Oral Solution [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748746", "drug_name": "Clindamycin 150 MG Oral Capsule [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748748", "drug_name": "Clindamycin 300 MG Oral Capsule [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748750", "drug_name": "Clindamycin 75 MG Oral Capsule [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748856", "drug_name": "Yaz 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748857", "drug_name": "Yasmin 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748859", "drug_name": "Zovia 1/35E 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748864", "drug_name": "Zovia 1/50E 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748865", "drug_name": "Trivora 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748879", "drug_name": "Levora 0.15/30 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748961", "drug_name": "{28 (Norethindrone 0.35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748962", "drug_name": "Camila 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748974", "drug_name": "Nor-QD 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748977", "drug_name": "Nora-BE 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "748987", "drug_name": "Ortho Micronor 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749148", "drug_name": "Leena 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749151", "drug_name": "Tri-Norinyl 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749157", "drug_name": "{7 (Ethinyl Estradiol 0.025 MG / norgestimate 0.18 MG Oral Tablet) / 7 (Ethinyl Estradiol 0.025 MG / norgestimate 0.215 MG Oral Tablet) / 7 (Ethinyl Estradiol 0.025 MG / norgestimate 0.25 MG Oral Tablet) / 7 (Inert Ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749158", "drug_name": "Ortho Tri-Cyclen Lo 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749196", "drug_name": "clopidogrel 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749198", "drug_name": "clopidogrel 300 MG Oral Tablet [Plavix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749210", "drug_name": "sevelamer carbonate 800 MG Oral Tablet [Renvela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749329", "drug_name": "Tretinoin 0.0005 MG/MG Topical Gel [Atralin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749737", "drug_name": "Ovcon 35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749761", "drug_name": "{7 (Ethinyl Estradiol 0.01 MG Oral Tablet) / 84 (Ethinyl Estradiol 0.03 MG / Levonorgestrel 0.15 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749762", "drug_name": "Seasonique 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749780", "drug_name": "{3 (Azithromycin 500 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749783", "drug_name": "{6 (Azithromycin 250 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749784", "drug_name": "{7 (Ethinyl Estradiol 0.035 MG / norgestimate 0.18 MG Oral Tablet) / 7 (Ethinyl Estradiol 0.035 MG / norgestimate 0.215 MG Oral Tablet) / 7 (Ethinyl Estradiol 0.035 MG / norgestimate 0.25 MG Oral Tablet) / 7 (Inert Ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749785", "drug_name": "Ortho Tri-Cyclen 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749802", "drug_name": "Fenofibrate 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749804", "drug_name": "Fenofibrate 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749813", "drug_name": "0.2 ML lanreotide 300 MG/ML Prefilled Syringe [Somatuline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749816", "drug_name": "0.5 ML lanreotide 240 MG/ML Prefilled Syringe [Somatuline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749818", "drug_name": "0.3 ML lanreotide 300 MG/ML Prefilled Syringe [Somatuline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749833", "drug_name": "Hydrochlorothiazide 12.5 MG / telmisartan 40 MG Oral Tablet [Micardis-HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749837", "drug_name": "Hydrochlorothiazide 12.5 MG / telmisartan 80 MG Oral Tablet [Micardis-HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749841", "drug_name": "Hydrochlorothiazide 25 MG / telmisartan 80 MG Oral Tablet [Micardis-HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749853", "drug_name": "Ortho-Novum 7/7/7 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749859", "drug_name": "Ortho-Novum 1/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749860", "drug_name": "{21 (Ethinyl Estradiol 0.035 MG / norgestimate 0.25 MG Oral Tablet) / 7 (Inert Ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749861", "drug_name": "Ortho-Cyclen 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749880", "drug_name": "Brevicon 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "749881", "drug_name": "Norinyl 1+35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750191", "drug_name": "Gramicidin 0.025 MG/ML / Neomycin 1.75 MG/ML / Polymyxin B 10000 UNT/ML Ophthalmic Solution [Neosporin Solution]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750199", "drug_name": "Amlodipine 10 MG / atorvastatin 10 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750203", "drug_name": "Amlodipine 10 MG / atorvastatin 20 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750207", "drug_name": "Amlodipine 10 MG / atorvastatin 40 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750211", "drug_name": "Amlodipine 10 MG / atorvastatin 80 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750215", "drug_name": "Amlodipine 2.5 MG / atorvastatin 40 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750219", "drug_name": "Amlodipine 2.5 MG / atorvastatin 20 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750223", "drug_name": "Amlodipine 2.5 MG / atorvastatin 10 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750227", "drug_name": "Amlodipine 5 MG / atorvastatin 10 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750231", "drug_name": "Amlodipine 5 MG / atorvastatin 20 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750235", "drug_name": "Amlodipine 5 MG / atorvastatin 40 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750239", "drug_name": "Amlodipine 5 MG / atorvastatin 80 MG Oral Tablet [Caduet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "750242", "drug_name": "{21 (Ethinyl Estradiol 0.05 MG / Norgestrel 0.5 MG Oral Tablet) / 7 (Inert Ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750243", "drug_name": "Ogestrel 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750244", "drug_name": "Low-Ogestrel 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750264", "drug_name": "Necon 7/7/7 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750265", "drug_name": "Cryselle 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750267", "drug_name": "Aranelle 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750268", "drug_name": "Aviane 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "750839", "drug_name": "erythromycin stearate 250 MG Oral Tablet [Erythrocin Stearate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751302", "drug_name": "24 HR rivastigmine 0.192 MG/HR Transdermal System [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751563", "drug_name": "{7 (lamotrigine 100 MG Oral Tablet) / 42 (lamotrigine 25 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751566", "drug_name": "Somatropin 8 MG/ML Injectable Solution [Serostim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751568", "drug_name": "Somatropin 5 MG Injection [Serostim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751570", "drug_name": "Somatropin 6 MG Injection [Serostim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751616", "drug_name": "nebivolol 10 MG Oral Tablet [Bystolic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751620", "drug_name": "nebivolol 2.5 MG Oral Tablet [Bystolic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751623", "drug_name": "nebivolol 5 MG Oral Tablet [Bystolic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751868", "drug_name": "Nortrel 0.5/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751871", "drug_name": "Nortrel 1/35 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751875", "drug_name": "Necon 0.5/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751879", "drug_name": "Necon 1/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751884", "drug_name": "Lutera 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751885", "drug_name": "Lessina 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751890", "drug_name": "Portia 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751901", "drug_name": "{84 (Ethinyl Estradiol 0.03 MG / Levonorgestrel 0.15 MG Oral Tablet) / 7 (Inert Ingredients 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751905", "drug_name": "Trinessa 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "751970", "drug_name": "0.5 ML Interferon gamma-1b 0.2 MG/ML Injection [Actimmune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "752376", "drug_name": "200 ACTUAT flunisolide 0.029 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "752388", "drug_name": "Insulin Lispro 25 UNT/ML / insulin lispro protamine, human 75 UNT/ML Injectable Suspension [Humalog Mix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "752869", "drug_name": "Mirtazapine 15 MG Disintegrating Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "752870", "drug_name": "Mirtazapine 30 MG Disintegrating Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "752871", "drug_name": "Mirtazapine 45 MG Disintegrating Oral Tablet [Remeron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753106", "drug_name": "terbinafine 125 MG Oral Granules [Lamisil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753108", "drug_name": "terbinafine 187.5 MG Oral Granules [Lamisil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753367", "drug_name": "Desogen 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753396", "drug_name": "Modicon 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753437", "drug_name": "9 HR Methylphenidate 1.11 MG/HR Transdermal System [Daytrana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753439", "drug_name": "9 HR Methylphenidate 1.67 MG/HR Transdermal System [Daytrana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753442", "drug_name": "9 HR Methylphenidate 2.22 MG/HR Transdermal System [Daytrana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753443", "drug_name": "9 HR Methylphenidate 3.33 MG/HR Transdermal System [Daytrana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753451", "drug_name": "{14 (lamotrigine 100 MG Oral Tablet) / 84 (lamotrigine 25 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753478", "drug_name": "Previfem 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753479", "drug_name": "Tri-Previfem 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753481", "drug_name": "Sprintec 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753482", "drug_name": "Apri 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753483", "drug_name": "Kelnor 1/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753543", "drug_name": "Reclipsen 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753544", "drug_name": "Sronyx 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "753557", "drug_name": "Omeprazole 40 MG / Sodium Bicarbonate 1680 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753562", "drug_name": "Omeprazole 20 MG / Sodium Bicarbonate 1680 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753601", "drug_name": "Omeprazole 40 MG / Sodium Bicarbonate 1680 MG Powder for Oral Suspension [Zegerid Reformulated Aug 2006]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753603", "drug_name": "Omeprazole 20 MG / Sodium Bicarbonate 1680 MG Powder for Oral Suspension [Zegerid Reformulated Aug 2006]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "753990", "drug_name": "Follicle Stimulating Hormone 75 UNT / Luteinizing Hormone 75 UNT Injection [Menopur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "754503", "drug_name": "olanzapine 10 MG Disintegrating Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754504", "drug_name": "olanzapine 15 MG Disintegrating Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754505", "drug_name": "olanzapine 20 MG Disintegrating Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754506", "drug_name": "olanzapine 5 MG Disintegrating Oral Tablet [Zyprexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754508", "drug_name": "{1 (aprepitant 125 MG Oral Capsule) / 2 (aprepitant 80 MG Oral Capsule) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754509", "drug_name": "Emend Tri-Fold Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "754512", "drug_name": "hydroxypropylcellulose 5 MG Drug Implant [Lacrisert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "754766", "drug_name": "Metronidazole 0.0075 MG/MG Vaginal Gel [MetroGel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "754890", "drug_name": "6-Aminocaproic Acid 250 MG/ML Oral Solution [Amicar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755298", "drug_name": "Zidovudine 10 MG/ML Oral Solution [Retrovir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "755357", "drug_name": "Ethosuximide 50 MG/ML Oral Solution [Zarontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755428", "drug_name": "Guaifenesin 40 MG/ML / Phenylephrine Hydrochloride 1 MG/ML Oral Solution [J-Max]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755470", "drug_name": "Lactulose 667 MG/ML Oral Solution [Enulose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755497", "drug_name": "Albuterol 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755661", "drug_name": "desloratadine 0.5 MG/ML Oral Solution [Clarinex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "755976", "drug_name": "Dexamethasone 0.1 MG/ML Oral Solution [Decadron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "756059", "drug_name": "lithium citrate 60 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "756209", "drug_name": "Zidovudine 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "756226", "drug_name": "Theophylline 5.33 MG/ML Oral Solution [Elixophyllin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "757594", "drug_name": "Jolivette 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "757969", "drug_name": "Prevpac Patient Therapy Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "758020", "drug_name": "Helidac Therapy Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "758027", "drug_name": "0.5 ML Interferon beta-1a 0.088 MG/ML Prefilled Syringe [Rebif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "758032", "drug_name": "0.5 ML Interferon beta-1a 0.044 MG/ML Prefilled Syringe [Rebif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "758523", "drug_name": "0.5 ML Sumatriptan 8 MG/ML Cartridge [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "758555", "drug_name": "etravirine 100 MG Oral Tablet [Intelence]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "759469", "drug_name": "Quasense 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "759473", "drug_name": "20 ACTUAT Zanamivir 5 MG/ACTUAT Dry Powder Inhaler [Relenza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "759481", "drug_name": "{51 (Dexamethasone 1.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "759697", "drug_name": "{35 (Dexamethasone 1.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "760029", "drug_name": "0.5 ML peginterferon alfa-2b 0.24 MG/ML Pen Injector [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "760039", "drug_name": "0.5 ML peginterferon alfa-2b 0.16 MG/ML Pen Injector [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "761974", "drug_name": "Cyclessa 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "761977", "drug_name": "Enpresse 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "761979", "drug_name": "{5 (moxifloxacin 400 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762001", "drug_name": "Kariva 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762002", "drug_name": "Mircette 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762003", "drug_name": "MonoNessa 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762004", "drug_name": "Necon 1/50 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762005", "drug_name": "Necon 10/11 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762007", "drug_name": "Nortrel 7/7/7 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762333", "drug_name": "Tri-Sprintec 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762334", "drug_name": "Velivet 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762394", "drug_name": "Prefest 30 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762660", "drug_name": "tadalafil 2.5 MG Oral Tablet [Cialis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "762663", "drug_name": "Jolessa 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762675", "drug_name": "{21 (Methylprednisolone 4 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762833", "drug_name": "0.25 ML Somatropin 0.8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762836", "drug_name": "0.25 ML Somatropin 1.6 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762839", "drug_name": "0.25 ML Somatropin 2.4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762843", "drug_name": "0.25 ML Somatropin 3.2 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762849", "drug_name": "0.25 ML Somatropin 4.8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762852", "drug_name": "0.25 ML Somatropin 5.6 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762859", "drug_name": "0.25 ML Somatropin 6.4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762868", "drug_name": "0.25 ML Somatropin 7.2 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762875", "drug_name": "0.25 ML Somatropin 4 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "762897", "drug_name": "0.25 ML Somatropin 8 MG/ML Prefilled Syringe [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763179", "drug_name": "{48 (Prednisone 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763181", "drug_name": "{21 (Prednisone 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763183", "drug_name": "{48 (Prednisone 10 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763185", "drug_name": "{21 (Prednisone 10 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763250", "drug_name": "Fenofibrate 120 MG Oral Tablet [Fenoglide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763252", "drug_name": "Fenofibrate 40 MG Oral Tablet [Fenoglide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763308", "drug_name": "pantoprazole 40 MG Oral Granules [Protonix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "763457", "drug_name": "rilonacept 220 MG Injection [Arcalyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "763472", "drug_name": "0.5 ML Alprostadil 0.02 MG/ML Prefilled Syringe [Caverject]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "763474", "drug_name": "0.5 ML Alprostadil 0.04 MG/ML Prefilled Syringe [Caverject]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "763489", "drug_name": "1 ML Somatropin 5 MG/ML Cartridge [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763521", "drug_name": "24 HR Nisoldipine 17 MG Extended Release Oral Tablet [Sular]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "763565", "drug_name": "0.4 ML adalimumab 50 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "763591", "drug_name": "24 HR Nisoldipine 34 MG Extended Release Oral Tablet [Sular]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790245", "drug_name": "0.5 ML peginterferon alfa-2b 0.3 MG/ML Pen Injector [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790247", "drug_name": "0.5 ML peginterferon alfa-2b 0.1 MG/ML Pen Injector [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790264", "drug_name": "24 HR Desvenlafaxine 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790267", "drug_name": "24 HR desvenlafaxine succinate 100 MG Extended Release Oral Tablet [Pristiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790276", "drug_name": "120 ACTUAT ciclesonide 0.05 MG/ACTUAT Nasal Inhaler [Omnaris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790284", "drug_name": "30 ACTUAT mometasone furoate 0.11 MG/ACTUAT Dry Powder Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "790288", "drug_name": "24 HR Desvenlafaxine 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790290", "drug_name": "24 HR desvenlafaxine succinate 50 MG Extended Release Oral Tablet [Pristiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790840", "drug_name": "24 HR Nisoldipine 8.5 MG Extended Release Oral Tablet [Sular]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "790889", "drug_name": "12 HR zileuton 600 MG Extended Release Oral Tablet [Zyflo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "792381", "drug_name": "Carbidopa 25 MG / Levodopa 100 MG Extended Release Oral Tablet [Sinemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "793741", "drug_name": "Sodium polystyrene sulfonate 250 MG/ML Oral Suspension [Kionex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "793872", "drug_name": "Isosorbide Dinitrate 40 MG Oral Tablet [Isordil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "793873", "drug_name": "Isosorbide Dinitrate 5 MG Oral Tablet [Isordil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "794246", "drug_name": "Avelox ABC Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "794610", "drug_name": "darunavir 600 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "794641", "drug_name": "lubiprostone 0.008 MG Oral Capsule [Amitiza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "795085", "drug_name": "certolizumab pegol 200 MG Injection [Cimzia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "795089", "drug_name": "Guaifenesin 388 MG / Phenylephrine 10 MG Oral Tablet [Gilphex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795097", "drug_name": "prednisolone 2 MG/ML Oral Solution [MILLIPRED]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795737", "drug_name": "Chantix Starting Month PAK", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795749", "drug_name": "Rebif Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795772", "drug_name": "Lamictal Blue (For Patients Taking Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795774", "drug_name": "Lamictal Orange (For Patients Not Taking Carbamazepine, Phenytoin, Phenobarbital, Primidone, or Rifampin and Not Taking Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795778", "drug_name": "Lamictal Green Kit (For Patients Taking Carbamazepine, Phenytoin, Phenobarbital, Primidone, or Rifampin and Not Taking Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "795858", "drug_name": "{10 (Prednisone 10 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "796918", "drug_name": "Somatropin 4.4 MG/ML Injectable Solution [Saizen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797022", "drug_name": "DexPak 10 Day TaperPak", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797023", "drug_name": "DexPak TaperPak 13 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797061", "drug_name": "Omeprazole 10 MG Granules for Oral Suspension [Prilosec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "797065", "drug_name": "Omeprazole 2.5 MG Granules for Oral Suspension [Prilosec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "797274", "drug_name": "Clindamycin 10 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797450", "drug_name": "Clindamycin 10 MG/ML Medicated Pad [Cleocin-T]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797452", "drug_name": "Erythromycin 20 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797697", "drug_name": "Flurandrenolide 0.004 MG/SQCM Medicated Tape [Cordran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "797819", "drug_name": "Benzoyl Peroxide 40 MG/ML Medicated Pad [Inova]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798049", "drug_name": "cadexomer iodine 9 MG/ML Medicated Pad [Iodoflex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798061", "drug_name": "adapalene 1 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798104", "drug_name": "eptacog alfa activated 0.001 MG Injection [Novoseven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798133", "drug_name": "Erythromycin 20 MG/ML Medicated Pad [Ery]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798274", "drug_name": "0.5 ML L1 protein, Human papillomavirus type 11 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 16 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 18 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 6 Vaccine 0.04 MG/ML Injection [Gardasil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798278", "drug_name": "0.5 ML L1 protein, Human papillomavirus type 11 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 16 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 18 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 6 Vaccine 0.04 MG/ML Prefilled Syringe [Gardasil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "798430", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.02 MG/ML Prefilled Syringe [Engerix-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "798502", "drug_name": "Benzoyl Peroxide 80 MG/ML Medicated Pad [Inova]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "799037", "drug_name": "60 ACTUAT ciclesonide 0.16 MG/ACTUAT Metered Dose Inhaler [Alvesco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "799040", "drug_name": "60 ACTUAT ciclesonide 0.08 MG/ACTUAT Metered Dose Inhaler [Alvesco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "799830", "drug_name": "dasatinib 100 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "799832", "drug_name": "24 HR ropinirole 2 MG Extended Release Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "800497", "drug_name": "24 HR ropinirole 4 MG Extended Release Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "800499", "drug_name": "24 HR ropinirole 8 MG Extended Release Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "800915", "drug_name": "Ascorbic Acid 4700 MG / POLYETHYLENE GLYCOL 3350 100000 MG / Potassium Chloride 1015 MG / Sodium Ascorbate 5900 MG / Sodium Chloride 2690 MG / sodium sulfate 7500 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "800918", "drug_name": "Ascorbic Acid 4700 MG / POLYETHYLENE GLYCOL 3350 100000 MG / Potassium Chloride 1015 MG / Sodium Ascorbate 5900 MG / Sodium Chloride 2690 MG / sodium sulfate 7500 MG Powder for Oral Solution [MoviPrep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "801057", "drug_name": "POLYETHYLENE GLYCOL 3350 420000 MG / Potassium Chloride 1480 MG / Sodium Bicarbonate 5720 MG / Sodium Chloride 11200 MG Powder for Oral Solution [NuLytely]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "801092", "drug_name": "NDA020983 60 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "801095", "drug_name": "NDA020983 60 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [Ventolin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "801185", "drug_name": "Ocella 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "801731", "drug_name": "alvimopan 12 MG Oral Capsule [Entereg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "801958", "drug_name": "0.5 ML Diazepam 5 MG/ML Rectal Gel [Diastat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "801962", "drug_name": "2 ML Diazepam 5 MG/ML Rectal Gel [Diastat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "801965", "drug_name": "4 ML Diazepam 5 MG/ML Rectal Gel [Diastat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "801966", "drug_name": "4 ML Diazepam 5 MG/ML Rectal Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "802059", "drug_name": "Hydrocortisone 1.67 MG/ML Enema [Colocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "802652", "drug_name": "1 ML Etanercept 50 MG/ML Prefilled Syringe [Enbrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "802762", "drug_name": "calcium ascorbate 150 MG / calcium threonate 2 MG / ferrous asparto glycinate 70 MG / liver stomach concentrate 50 MG / succinic acid 75 MG / vitamin B12 0.01 MG Oral Tablet [Multigen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "802780", "drug_name": "Urea 500 MG/ML Topical Cream [Remeven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803194", "drug_name": "insulin glulisine, human 100 UNT/ML Injectable Solution [Apidra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803348", "drug_name": "Phentermine Hydrochloride 37.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803350", "drug_name": "Phentermine Hydrochloride 37.5 MG Oral Capsule [Adipex-P]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803353", "drug_name": "Phentermine Hydrochloride 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803354", "drug_name": "Phentermine Hydrochloride 37.5 MG Oral Tablet [Adipex-P]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "803367", "drug_name": "1 ML Hepatitis A Vaccine (Inactivated) Strain HM175 720 UNT/ML / Hepatitis B Surface Antigen Vaccine 0.02 MG/ML Injection [Twinrix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "804547", "drug_name": "difluprednate 0.5 MG/ML Ophthalmic Suspension [Durezol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "804973", "drug_name": "Clindamycin 10 MG/ML Topical Lotion [Cleocin-T]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "804975", "drug_name": "Clindamycin 10 MG/ML Topical Solution [Cleocin-T]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "804978", "drug_name": "Clindamycin 0.01 MG/MG Topical Gel [Cleocin-T]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805007", "drug_name": "peginterferon alfa-2b 0.05 MG Injection [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805009", "drug_name": "peginterferon alfa-2b 0.12 MG Injection [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805010", "drug_name": "peginterferon alfa-2b 0.15 MG Injection [Pegintron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805370", "drug_name": "Tretinoin 0.0004 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805372", "drug_name": "Tretinoin 0.001 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805462", "drug_name": "Tetrabenazine 25 MG Oral Tablet [Xenazine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805464", "drug_name": "Tetrabenazine 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805466", "drug_name": "Tetrabenazine 12.5 MG Oral Tablet [Xenazine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805515", "drug_name": "tipranavir 100 MG/ML Oral Solution [Aptivus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805659", "drug_name": "armodafinil 150 MG Oral Tablet [Nuvigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805661", "drug_name": "armodafinil 250 MG Oral Tablet [Nuvigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805663", "drug_name": "armodafinil 50 MG Oral Tablet [Nuvigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "805678", "drug_name": "20 ML Baclofen 0.5 MG/ML Injection [Lioresal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805679", "drug_name": "1 ML Baclofen 0.05 MG/ML Injection [Lioresal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805855", "drug_name": "candesartan cilexetil 32 MG / Hydrochlorothiazide 25 MG Oral Tablet [Atacand HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805859", "drug_name": "candesartan cilexetil 32 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Atacand HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "805863", "drug_name": "candesartan cilexetil 16 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Atacand HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "806297", "drug_name": "Risperidone 0.5 MG Disintegrating Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "806298", "drug_name": "Risperidone 1 MG Disintegrating Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "806299", "drug_name": "Risperidone 2 MG Disintegrating Oral Tablet [Risperdal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "807283", "drug_name": "Levonorgestrel 0.000833 MG/HR Intrauterine System [Mirena]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "807832", "drug_name": "24 HR Levetiracetam 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "807834", "drug_name": "24 HR Levetiracetam 500 MG Extended Release Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "808744", "drug_name": "24 HR venlafaxine 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "808748", "drug_name": "24 HR venlafaxine 225 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "808751", "drug_name": "24 HR venlafaxine 37.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "808753", "drug_name": "24 HR venlafaxine 75 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "808917", "drug_name": "Fosfomycin 3000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "808921", "drug_name": "Fosfomycin 3000 MG Powder for Oral Solution [Monurol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809014", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 80 MG Oral Tablet [Diovan HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809018", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet [Diovan HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809022", "drug_name": "Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet [Diovan HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809026", "drug_name": "Hydrochlorothiazide 12.5 MG / valsartan 320 MG Oral Tablet [Diovan HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809030", "drug_name": "Hydrochlorothiazide 25 MG / valsartan 320 MG Oral Tablet [Diovan HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809159", "drug_name": "0.5 ML Etanercept 50 MG/ML Prefilled Syringe [Enbrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "809316", "drug_name": "Benzoyl Peroxide 40 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809406", "drug_name": "Iron Carbonyl 45 MG Oral Tablet [Feosol Caplet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809481", "drug_name": "silodosin 8 MG Oral Capsule [Rapaflo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809854", "drug_name": "Hydrochlorothiazide 12.5 MG / quinapril 10 MG Oral Tablet [Accuretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809858", "drug_name": "Hydrochlorothiazide 12.5 MG / quinapril 20 MG Oral Tablet [Accuretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809871", "drug_name": "C1 esterase inhibitor (human) 500 UNT Injection [Cinryze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809990", "drug_name": "lacosamide 100 MG Oral Tablet [Vimpat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809994", "drug_name": "lacosamide 150 MG Oral Tablet [Vimpat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "809998", "drug_name": "lacosamide 200 MG Oral Tablet [Vimpat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810002", "drug_name": "lacosamide 50 MG Oral Tablet [Vimpat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810075", "drug_name": "24 HR Fesoterodine Fumarate 4 MG Extended Release Oral Tablet [Toviaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810079", "drug_name": "24 HR Fesoterodine Fumarate 8 MG Extended Release Oral Tablet [Toviaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810083", "drug_name": "Carbidopa 31.25 MG / entacapone 200 MG / Levodopa 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810087", "drug_name": "Carbidopa 31.25 MG / entacapone 200 MG / Levodopa 125 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810090", "drug_name": "Carbidopa 18.75 MG / entacapone 200 MG / Levodopa 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810094", "drug_name": "Carbidopa 18.75 MG / entacapone 200 MG / Levodopa 75 MG Oral Tablet [Stalevo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810096", "drug_name": "{7 (Ethinyl Estradiol 0.01 MG Oral Tablet) / 84 (Ethinyl Estradiol 0.02 MG / Levonorgestrel 0.1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "810097", "drug_name": "LoSeasonique 91 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "823934", "drug_name": "Hydrochlorothiazide 12.5 MG / irbesartan 150 MG Oral Tablet [Avalide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "823938", "drug_name": "Hydrochlorothiazide 12.5 MG / irbesartan 300 MG Oral Tablet [Avalide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "823971", "drug_name": "Hydrochlorothiazide 25 MG / Lisinopril 20 MG Oral Tablet [Zestoretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "823982", "drug_name": "Hydrochlorothiazide 12.5 MG / Lisinopril 20 MG Oral Tablet [Zestoretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "823986", "drug_name": "Hydrochlorothiazide 12.5 MG / Lisinopril 10 MG Oral Tablet [Zestoretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824190", "drug_name": "Amoxicillin 500 MG / Clavulanate 125 MG Oral Tablet [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824194", "drug_name": "Amoxicillin 875 MG / Clavulanate 125 MG Oral Tablet [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824299", "drug_name": "rufinamide 200 MG Oral Tablet [Banzel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824303", "drug_name": "rufinamide 400 MG Oral Tablet [Banzel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824889", "drug_name": "prednisolone 4 MG/ML Oral Solution [Veripred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "824961", "drug_name": "24 HR ropinirole 12 MG Extended Release Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825005", "drug_name": "168 HR Granisetron 0.129 MG/HR Transdermal System [Sancuso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "825130", "drug_name": "24 HR mesalamine 375 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825134", "drug_name": "24 HR mesalamine 375 MG Extended Release Oral Capsule [Apriso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825170", "drug_name": "Humira Pen 40 MG/0.8 ML - Crohn's Disease Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "825180", "drug_name": "Aspirin 81 MG Chewable Tablet [Bayer Aspirin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825321", "drug_name": "Acyclovir 50 MG/ML Topical Cream [Zovirax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825325", "drug_name": "0.375 ML Leuprolide Acetate 120 MG/ML Prefilled Syringe [Eligard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825333", "drug_name": "0.5 ML Leuprolide Acetate 60 MG/ML Prefilled Syringe [Eligard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825334", "drug_name": "0.25 ML Leuprolide Acetate 30 MG/ML Prefilled Syringe [Eligard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825335", "drug_name": "0.375 ML Leuprolide Acetate 60 MG/ML Prefilled Syringe [Eligard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "825425", "drug_name": "eltrombopag 25 MG Oral Tablet [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "825429", "drug_name": "eltrombopag 50 MG Oral Tablet [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "826614", "drug_name": "silodosin 4 MG Oral Capsule [Rapaflo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "827075", "drug_name": "nebivolol 20 MG Oral Tablet [Bystolic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "827185", "drug_name": "Ranitidine 300 MG Oral Tablet [Zantac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "827189", "drug_name": "Ranitidine 150 MG Oral Tablet [Zantac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828246", "drug_name": "Amoxicillin 775 MG Extended Release Oral Tablet [Moxatag]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828248", "drug_name": "cortisone acetate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828299", "drug_name": "Cyclobenzaprine hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828301", "drug_name": "Cyclobenzaprine hydrochloride 7.5 MG Oral Tablet [Fexmid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828320", "drug_name": "Cyclobenzaprine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828348", "drug_name": "Cyclobenzaprine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828353", "drug_name": "24 HR Cyclobenzaprine hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828355", "drug_name": "24 HR Cyclobenzaprine hydrochloride 30 MG Extended Release Oral Capsule [Amrix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828358", "drug_name": "24 HR Cyclobenzaprine hydrochloride 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828359", "drug_name": "24 HR Cyclobenzaprine hydrochloride 15 MG Extended Release Oral Capsule [Amrix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828364", "drug_name": "hydrocortisone acetate 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Rectal Foam [Proctofoam-HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828377", "drug_name": "fenofibric acid 135 MG Delayed Release Oral Capsule [Trilipix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828381", "drug_name": "fenofibric acid 45 MG Delayed Release Oral Capsule [Trilipix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "828536", "drug_name": "rizatriptan 5 MG Disintegrating Oral Tablet [Maxalt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "828537", "drug_name": "rizatriptan 10 MG Disintegrating Oral Tablet [Maxalt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "828696", "drug_name": "Zolpidem tartrate 5 MG/ACTUAT Oral Spray [Zolpimist]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "828703", "drug_name": "1.2 ML Plerixafor 20 MG/ML Injection [Mozobil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "829031", "drug_name": "methenamine mandelate 500 MG / Sodium Phosphate, Monobasic 500 MG Oral Tablet [Uroqid-Acid No.2]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "829502", "drug_name": "Mefenamic Acid 250 MG Oral Capsule [Ponstel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "829989", "drug_name": "0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / Hepatitis B Surface Antigen Vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "830245", "drug_name": "1 ML Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled Syringe [Recombivax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "830253", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled Syringe [Recombivax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "830263", "drug_name": "1 ML Hepatitis B Surface Antigen Vaccine 0.04 MG/ML Injection [Recombivax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "830605", "drug_name": "Doxycycline Monohydrate 100 MG Oral Tablet [Avidoxy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830642", "drug_name": "calcium acetate 667 MG Oral Tablet [Eliphos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830648", "drug_name": "adapalene 0.001 MG/MG / Benzoyl Peroxide 0.025 MG/MG Topical Gel [Epiduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830761", "drug_name": "Hydrocortisone 20 MG/ML Topical Lotion [Scalacort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830795", "drug_name": "24 HR Diltiazem Hydrochloride 360 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830798", "drug_name": "24 HR Diltiazem Hydrochloride 360 MG Extended Release Oral Capsule [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830801", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830803", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830837", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830839", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830845", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830847", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830861", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830863", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830865", "drug_name": "12 HR Diltiazem Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830869", "drug_name": "12 HR Diltiazem Hydrochloride 90 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830872", "drug_name": "12 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830876", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830878", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830880", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830883", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830898", "drug_name": "24 HR Diltiazem Hydrochloride 360 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "830902", "drug_name": "24 HR Diltiazem Hydrochloride 420 MG Extended Release Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831054", "drug_name": "Diltiazem Hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831055", "drug_name": "Diltiazem Hydrochloride 120 MG Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831102", "drug_name": "Diltiazem Hydrochloride 90 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831103", "drug_name": "Diltiazem Hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831109", "drug_name": "Cromolyn Sodium 40 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831193", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831196", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Taztia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831215", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831226", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831244", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831246", "drug_name": "Cromolyn Sodium 10 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831248", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Taztia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831252", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831255", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831269", "drug_name": "Cromolyn Sodium 20 MG/ML Oral Solution [Gastrocrom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831285", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831296", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831300", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Taztia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831309", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831323", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831325", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Taztia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831337", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Dilt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831338", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Cartia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831347", "drug_name": "24 HR Diltiazem Hydrochloride 360 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831359", "drug_name": "24 HR Diltiazem Hydrochloride 420 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831360", "drug_name": "24 HR Diltiazem Hydrochloride 420 MG Extended Release Oral Capsule [Tiazac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831393", "drug_name": "Miconazole Nitrate 0.0025 MG/MG / Petrolatum 0.814 MG/MG / Zinc Oxide 0.15 MG/MG Topical Ointment [Vusion]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831460", "drug_name": "Desmopressin Acetate 0.15 MG/ACTUAT Nasal Spray [Stimate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831509", "drug_name": "fibrinogen concentrate (human) 1 MG Injection [RiaSTAP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831533", "drug_name": "Errin 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "831870", "drug_name": "darunavir 75 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "831872", "drug_name": "Azurette 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "832718", "drug_name": "Potassium Chloride 8 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "832731", "drug_name": "Microencapsulated Potassium Chloride 15 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "832891", "drug_name": "Potassium Chloride 20 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833008", "drug_name": "Desmopressin Acetate 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833139", "drug_name": "Milnacipran hydrochloride 100 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833143", "drug_name": "Milnacipran hydrochloride 12.5 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833146", "drug_name": "Milnacipran hydrochloride 50 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833149", "drug_name": "Milnacipran hydrochloride 25 MG Oral Tablet [Savella]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833151", "drug_name": "Savella 4-Week Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833164", "drug_name": "Itraconazole 100 MG Oral Capsule [Sporanox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "833217", "drug_name": "Diltiazem Hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833219", "drug_name": "Diltiazem Hydrochloride 30 MG Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833234", "drug_name": "mesalamine 800 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833461", "drug_name": "Betamethasone 0.5 MG/ML / calcipotriene 0.05 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833463", "drug_name": "Betamethasone 0.5 MG/ML / calcipotriene 0.05 MG/ML Topical Lotion [Taclonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833470", "drug_name": "Levalbuterol 0.417 MG/ML Inhalation Solution [Xopenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833472", "drug_name": "Betamethasone 0.0005 MG/MG / calcipotriene 0.00005 MG/MG Topical Ointment [Taclonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833507", "drug_name": "Scalacort DK Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833528", "drug_name": "Amiodarone hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833530", "drug_name": "Amiodarone hydrochloride 200 MG Oral Tablet [Cordarone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "833709", "drug_name": "24 HR tramadol hydrochloride 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "833711", "drug_name": "24 HR tramadol hydrochloride 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "833713", "drug_name": "24 HR tramadol hydrochloride 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834022", "drug_name": "Ketorolac Tromethamine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "834023", "drug_name": "Medrol Dosepak", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834040", "drug_name": "Penicillin V Potassium 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834046", "drug_name": "Penicillin V Potassium 25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834061", "drug_name": "Penicillin V Potassium 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834102", "drug_name": "Penicillin V Potassium 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834127", "drug_name": "chlorhexidine gluconate 1.2 MG/ML Mouthwash", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834135", "drug_name": "chlorhexidine gluconate 1.2 MG/ML Mouthwash [Peridex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834137", "drug_name": "chlorhexidine gluconate 1.2 MG/ML Mouthwash [Periogard]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834206", "drug_name": "chlorhexidine gluconate 200 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "834235", "drug_name": "febuxostat 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834239", "drug_name": "febuxostat 40 MG Oral Tablet [Uloric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834241", "drug_name": "febuxostat 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834243", "drug_name": "febuxostat 80 MG Oral Tablet [Uloric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834341", "drug_name": "Carbidopa 50 MG / Levodopa 200 MG Extended Release Oral Tablet [Sinemet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834346", "drug_name": "Amiodarone hydrochloride 200 MG Oral Tablet [Pacerone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834348", "drug_name": "Amiodarone hydrochloride 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834350", "drug_name": "Amiodarone hydrochloride 400 MG Oral Tablet [Pacerone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834393", "drug_name": "Diltiazem Hydrochloride 60 MG Oral Tablet [Cardizem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "834768", "drug_name": "Caziant 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835560", "drug_name": "Naproxen 500 MG Delayed Release Oral Tablet [Naprosyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835564", "drug_name": "Imipramine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835566", "drug_name": "Imipramine Hydrochloride 25 MG Oral Tablet [Tofranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835568", "drug_name": "Imipramine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835570", "drug_name": "Imipramine Hydrochloride 50 MG Oral Tablet [Tofranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835572", "drug_name": "Imipramine pamoate 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835577", "drug_name": "Imipramine pamoate 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835589", "drug_name": "Imipramine pamoate 125 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835591", "drug_name": "Imipramine pamoate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835593", "drug_name": "Imipramine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835596", "drug_name": "Imipramine Hydrochloride 10 MG Oral Tablet [Tofranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835603", "drug_name": "tramadol hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "835605", "drug_name": "tramadol hydrochloride 50 MG Oral Tablet [Ultram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "835721", "drug_name": "Ethionamide 250 MG Oral Tablet [Trecator]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835726", "drug_name": "Acamprosate calcium 333 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835809", "drug_name": "testosterone enanthate 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835829", "drug_name": "testosterone cypionate 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835831", "drug_name": "testosterone cypionate 100 MG/ML Injectable Solution [Depo-testosterone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835835", "drug_name": "cyclosporine, modified 100 MG Oral Capsule [Gengraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835840", "drug_name": "testosterone cypionate 200 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835842", "drug_name": "testosterone cypionate 200 MG/ML Injectable Solution [Depo-testosterone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835886", "drug_name": "cyclosporine, modified 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835892", "drug_name": "cyclosporine, modified 100 MG/ML Oral Solution [Gengraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835894", "drug_name": "cyclosporine, modified 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835896", "drug_name": "cyclosporine, modified 25 MG Oral Capsule [Gengraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835899", "drug_name": "cyclosporine, modified 100 MG/ML Oral Solution [Neoral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835909", "drug_name": "cyclosporine, modified 25 MG Oral Capsule [Neoral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835911", "drug_name": "cyclosporine, modified 100 MG Oral Capsule [Neoral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835913", "drug_name": "Mefloquine Hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835925", "drug_name": "cyclosporine, modified 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "835958", "drug_name": "Amiodarone hydrochloride 100 MG Oral Tablet [Pacerone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836281", "drug_name": "165 ACTUAT Ipratropium Bromide 0.042 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836292", "drug_name": "345 ACTUAT Ipratropium Bromide 0.021 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836358", "drug_name": "Ipratropium Bromide 0.2 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836364", "drug_name": "165 ACTUAT Ipratropium Bromide 0.042 MG/ACTUAT Nasal Inhaler [Atrovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836368", "drug_name": "200 ACTUAT Ipratropium Bromide 0.017 MG/ACTUAT Metered Dose Inhaler [Atrovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836372", "drug_name": "345 ACTUAT Ipratropium Bromide 0.021 MG/ACTUAT Nasal Inhaler [Atrovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836395", "drug_name": "Acetaminophen 325 MG / tramadol hydrochloride 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "836397", "drug_name": "Acetaminophen 325 MG / tramadol hydrochloride 37.5 MG Oral Tablet [Ultracet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "836645", "drug_name": "Zolpidem tartrate 10 MG Sublingual Tablet [Edluar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "836649", "drug_name": "Zolpidem tartrate 5 MG Sublingual Tablet [Edluar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "844590", "drug_name": "Theophylline 100 MG Extended Release Oral Capsule [Theo-24]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "844591", "drug_name": "Theophylline 300 MG Extended Release Oral Capsule [Theo-24]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "844813", "drug_name": "Theophylline 200 MG Extended Release Oral Capsule [Theo-24]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "844829", "drug_name": "Theophylline 400 MG Extended Release Oral Capsule [Theo-24]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845316", "drug_name": "24 HR tramadol hydrochloride 300 MG Extended Release Oral Tablet [Ultram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845478", "drug_name": "topiramate 15 MG Oral Capsule [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845479", "drug_name": "topiramate 25 MG Oral Capsule [Topamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845488", "drug_name": "Ramipril 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845489", "drug_name": "Ramipril 1.25 MG Oral Capsule [Altace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845512", "drug_name": "everolimus 10 MG Oral Tablet [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "845515", "drug_name": "everolimus 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "845518", "drug_name": "everolimus 5 MG Oral Tablet [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "845988", "drug_name": "Benzoyl Peroxide 70 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "845992", "drug_name": "Benzoyl Peroxide 70 MG/ML Medicated Liquid Soap [Pacnex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "846192", "drug_name": "{21 (Dexamethasone 1.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "846378", "drug_name": "24 HR Levetiracetam 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847042", "drug_name": "Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet [Benicar HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847055", "drug_name": "Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet [Benicar HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847060", "drug_name": "Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 20 MG Oral Tablet [Benicar HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847131", "drug_name": "Benzoyl Peroxide 60 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847189", "drug_name": "3 ML insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Pen Injector [Humulin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847191", "drug_name": "3 ML insulin aspart protamine, human 70 UNT/ML / insulin aspart, human 30 UNT/ML Pen Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847199", "drug_name": "3 ML insulin isophane, human 100 UNT/ML Pen Injector [Humulin N]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847225", "drug_name": "DexPak TaperPak 6 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847232", "drug_name": "3 ML Insulin Glargine 100 UNT/ML Pen Injector [Lantus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847241", "drug_name": "3 ML insulin detemir 100 UNT/ML Pen Injector [Levemir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847245", "drug_name": "1.5 ML Somatropin 10 MG/ML Pen Injector [Norditropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847247", "drug_name": "1.5 ML Somatropin 3.33 MG/ML Pen Injector [Norditropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847249", "drug_name": "Urea 420 MG/ML Topical Foam [Kerafoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847252", "drug_name": "3 ML Insulin Lispro 25 UNT/ML / insulin lispro protamine, human 75 UNT/ML Pen Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847261", "drug_name": "3 ML insulin glulisine, human 100 UNT/ML Pen Injector [Apidra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847348", "drug_name": "1.5 ML Somatropin 6.67 MG/ML Pen Injector [Norditropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847360", "drug_name": "cefditoren pivoxil 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847362", "drug_name": "cefditoren pivoxil 400 MG Oral Tablet [Spectracef]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847488", "drug_name": "24 HR Ciprofloxacin 1000 MG Extended Release Oral Tablet [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847673", "drug_name": "24 HR Levetiracetam 750 MG Extended Release Oral Tablet [Keppra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847734", "drug_name": "artemether 20 MG / lumefantrine 120 MG Oral Tablet [Coartem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "847741", "drug_name": "lopinavir 200 MG / Ritonavir 50 MG Oral Tablet [Kaletra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847745", "drug_name": "lopinavir 100 MG / Ritonavir 25 MG Oral Tablet [Kaletra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847749", "drug_name": "lopinavir 80 MG/ML / Ritonavir 20 MG/ML Oral Solution [Kaletra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847913", "drug_name": "60 ACTUAT exenatide 0.01 MG/ACTUAT Pen Injector [Byetta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "847917", "drug_name": "60 ACTUAT exenatide 0.005 MG/ACTUAT Pen Injector [Byetta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848119", "drug_name": "Erythromycin 333 MG Delayed Release Oral Tablet [PCE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848121", "drug_name": "Erythromycin 500 MG Delayed Release Oral Tablet [PCE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848131", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848134", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet [Exforge HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848135", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / valsartan 320 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848139", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / valsartan 320 MG Oral Tablet [Exforge HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848140", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848144", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / valsartan 160 MG Oral Tablet [Exforge HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848145", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848149", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet [Exforge HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848151", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848155", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / valsartan 160 MG Oral Tablet [Exforge HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848164", "drug_name": "0.5 ML golimumab 100 MG/ML Prefilled Syringe [Simponi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848176", "drug_name": "Augmented Betamethasone 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848178", "drug_name": "Augmented Betamethasone 0.5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848180", "drug_name": "Augmented Betamethasone 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848195", "drug_name": "Augmented Betamethasone 0.5 MG/ML Topical Cream [Diprolene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848197", "drug_name": "Augmented Betamethasone 0.5 MG/ML Topical Lotion [Diprolene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848200", "drug_name": "Augmented Betamethasone 0.0005 MG/MG Topical Ointment [Diprolene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848208", "drug_name": "Augmented Betamethasone 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848330", "drug_name": "90 DAY Estradiol 0.000313 MG/HR Vaginal System [Estring]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848333", "drug_name": "90 DAY Estradiol 0.00208 MG/HR Vaginal System [Femring]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848343", "drug_name": "90 DAY Estradiol 0.00417 MG/HR Vaginal System [Femring]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848584", "drug_name": "24 HR ropinirole 6 MG Extended Release Oral Tablet [Requip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848726", "drug_name": "iloperidone 1 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848730", "drug_name": "iloperidone 10 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848734", "drug_name": "iloperidone 12 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848738", "drug_name": "iloperidone 2 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848742", "drug_name": "iloperidone 4 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848746", "drug_name": "iloperidone 6 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848750", "drug_name": "iloperidone 8 MG Oral Tablet [Fanapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848752", "drug_name": "Fanapt Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "848768", "drug_name": "Aspirin 325 MG / Oxycodone Hydrochloride 4.84 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848943", "drug_name": "Cholestyramine Resin 4000 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848949", "drug_name": "Cholestyramine Resin 4000 MG Powder for Oral Suspension [Questran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848951", "drug_name": "Sugar-Free Cholestyramine Resin 4000 MG Powder for Oral Suspension [Prevalite]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "848960", "drug_name": "Ciprofloxacin 2 MG/ML Otic Solution [Cetraxal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849049", "drug_name": "lamotrigine 100 MG Disintegrating Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849050", "drug_name": "lamotrigine 200 MG Disintegrating Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849051", "drug_name": "lamotrigine 25 MG Disintegrating Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849052", "drug_name": "lamotrigine 50 MG Disintegrating Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849383", "drug_name": "mesalamine 800 MG Delayed Release Oral Tablet [Asacol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849385", "drug_name": "Amantadine Hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849389", "drug_name": "Amantadine Hydrochloride 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849395", "drug_name": "Amantadine Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849398", "drug_name": "Naproxen sodium 275 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849431", "drug_name": "Naproxen sodium 550 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849438", "drug_name": "Naproxen sodium 550 MG Oral Tablet [Anaprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849452", "drug_name": "Naproxen sodium 500 MG / Sumatriptan 85 MG Oral Tablet [Treximet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "849501", "drug_name": "Desmopressin Acetate 0.004 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849503", "drug_name": "Desmopressin Acetate 0.004 MG/ML Injectable Solution [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849506", "drug_name": "Desmopressin Acetate 0.01 MG/ACTUAT Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849508", "drug_name": "Desmopressin Acetate 0.01 MG/ACTUAT Nasal Spray [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849515", "drug_name": "Desmopressin Acetate 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849517", "drug_name": "Desmopressin Acetate 0.1 MG Oral Tablet [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849520", "drug_name": "Desmopressin Acetate 0.1 MG/ML Nasal Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849522", "drug_name": "Desmopressin Acetate 0.1 MG/ML Nasal Solution [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849524", "drug_name": "Desmopressin Acetate 0.2 MG Oral Tablet [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849580", "drug_name": "Sulfamethoxazole 800 MG / Trimethoprim 160 MG Oral Tablet [Bactrim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849599", "drug_name": "1 ML certolizumab pegol 200 MG/ML Prefilled Syringe [Cimzia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "849650", "drug_name": "Urea 350 MG/ML Topical Foam [Hydro 35]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849827", "drug_name": "tolvaptan 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849831", "drug_name": "tolvaptan 15 MG Oral Tablet [Samsca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849833", "drug_name": "tolvaptan 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849835", "drug_name": "tolvaptan 30 MG Oral Tablet [Samsca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849851", "drug_name": "3 ML Somatropin 10 MG/ML Pen Injector [Norditropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "849866", "drug_name": "Pulmonary Hypertension tadalafil 20 MG Oral Tablet [Adcirca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "849928", "drug_name": "caffeine citrate 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "850309", "drug_name": "besifloxacin 6 MG/ML Ophthalmic Suspension [Besivance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "850457", "drug_name": "darunavir 150 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "851749", "drug_name": "Lamictal ODT Blue Patient Titration Kit (for Patients Taking Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "851751", "drug_name": "Lamictal ODT Orange Patient Titration Kit (For Patients Not Taking Enzyme-Inducing Drugs or Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "851753", "drug_name": "Lamictal ODT Green Titration Kit (for Patients Taking Enzyme-Inducing Drugs and Not Taking Valproate)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "852877", "drug_name": "Quinidine Sulfate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "852906", "drug_name": "Quinidine Sulfate 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "852913", "drug_name": "Quinidine Sulfate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "852920", "drug_name": "quinidine gluconate 324 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "853201", "drug_name": "24 HR quetiapine 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "853202", "drug_name": "24 HR quetiapine 50 MG Extended Release Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "853354", "drug_name": "0.5 ML ustekinumab 90 MG/ML Prefilled Syringe [Stelara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "853356", "drug_name": "1 ML ustekinumab 90 MG/ML Prefilled Syringe [Stelara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "853486", "drug_name": "60 ACTUAT Nafarelin 0.2 MG/ACTUAT Nasal Inhaler [Synarel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854140", "drug_name": "tapentadol 100 MG Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854142", "drug_name": "tapentadol 50 MG Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854144", "drug_name": "tapentadol 75 MG Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854228", "drug_name": "0.3 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854232", "drug_name": "0.3 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854235", "drug_name": "0.4 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854236", "drug_name": "0.4 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854238", "drug_name": "0.6 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854239", "drug_name": "0.6 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854241", "drug_name": "0.8 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854242", "drug_name": "0.8 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854245", "drug_name": "0.8 ML Enoxaparin sodium 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854247", "drug_name": "0.8 ML Enoxaparin sodium 150 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854248", "drug_name": "1 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854249", "drug_name": "1 ML Enoxaparin sodium 100 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854252", "drug_name": "1 ML Enoxaparin sodium 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854253", "drug_name": "1 ML Enoxaparin sodium 150 MG/ML Prefilled Syringe [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854256", "drug_name": "Enoxaparin sodium 100 MG/ML Injectable Solution [Lovenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854302", "drug_name": "1.5 ML Somatropin 6.67 MG/ML Cartridge [Omnitrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854801", "drug_name": "Diclofenac Sodium 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854832", "drug_name": "lisdexamfetamine dimesylate 20 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854836", "drug_name": "lisdexamfetamine dimesylate 30 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854840", "drug_name": "lisdexamfetamine dimesylate 40 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854844", "drug_name": "lisdexamfetamine dimesylate 70 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854848", "drug_name": "lisdexamfetamine dimesylate 60 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854852", "drug_name": "lisdexamfetamine dimesylate 50 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854859", "drug_name": "dronedarone 400 MG Oral Tablet [Multaq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854868", "drug_name": "Rabeprazole sodium 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854870", "drug_name": "Rabeprazole sodium 20 MG Delayed Release Oral Tablet [Aciphex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854873", "drug_name": "Zolpidem tartrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854875", "drug_name": "Zolpidem tartrate 10 MG Oral Tablet [Ambien]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854876", "drug_name": "Zolpidem tartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854878", "drug_name": "Zolpidem tartrate 5 MG Oral Tablet [Ambien]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854880", "drug_name": "Zolpidem tartrate 12.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854882", "drug_name": "Zolpidem tartrate 12.5 MG Extended Release Oral Tablet [Ambien]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854894", "drug_name": "Zolpidem tartrate 6.25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854896", "drug_name": "Zolpidem tartrate 6.25 MG Extended Release Oral Tablet [Ambien]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854901", "drug_name": "Bisoprolol Fumarate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854903", "drug_name": "Bisoprolol Fumarate 10 MG Oral Tablet [Zebeta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854905", "drug_name": "Bisoprolol Fumarate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854907", "drug_name": "Bisoprolol Fumarate 5 MG Oral Tablet [Zebeta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854908", "drug_name": "Bisoprolol Fumarate 10 MG / Hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854910", "drug_name": "Bisoprolol Fumarate 10 MG / Hydrochlorothiazide 6.25 MG Oral Tablet [Ziac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854916", "drug_name": "Bisoprolol Fumarate 2.5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854918", "drug_name": "Bisoprolol Fumarate 2.5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet [Ziac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854919", "drug_name": "Bisoprolol Fumarate 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854921", "drug_name": "Bisoprolol Fumarate 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet [Ziac]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854925", "drug_name": "Perindopril Erbumine 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854927", "drug_name": "Perindopril Erbumine 8 MG Oral Tablet [Aceon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854981", "drug_name": "Streptococcus pneumoniae type 1 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 10A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 11A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 12F capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 14 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 15B capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoni", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "854984", "drug_name": "Perindopril Erbumine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854988", "drug_name": "Perindopril Erbumine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854990", "drug_name": "Perindopril Erbumine 4 MG Oral Tablet [Aceon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854995", "drug_name": "Colistin 3 MG/ML / Hydrocortisone 10 MG/ML / Neomycin 3.3 MG/ML / THONZONIUM BROMIDE 0.5 MG/ML Otic Suspension [Coly Mycin S]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "854997", "drug_name": "Colistin 3 MG/ML / Hydrocortisone 10 MG/ML / Neomycin 3.3 MG/ML / THONZONIUM BROMIDE 0.5 MG/ML Otic Suspension [Cortisporin-TC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855168", "drug_name": "levocetirizine dihydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855170", "drug_name": "levocetirizine dihydrochloride 0.5 MG/ML Oral Solution [Xyzal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855172", "drug_name": "levocetirizine dihydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855174", "drug_name": "levocetirizine dihydrochloride 5 MG Oral Tablet [Xyzal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855178", "drug_name": "tolterodine tartrate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855180", "drug_name": "tolterodine tartrate 1 MG Oral Tablet [Detrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855182", "drug_name": "24 HR tolterodine tartrate 2 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855184", "drug_name": "24 HR tolterodine tartrate 2 MG Extended Release Oral Capsule [Detrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855189", "drug_name": "24 HR tolterodine tartrate 4 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855191", "drug_name": "24 HR tolterodine tartrate 4 MG Extended Release Oral Capsule [Detrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855194", "drug_name": "tolterodine tartrate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855195", "drug_name": "tolterodine tartrate 2 MG Oral Tablet [Detrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855200", "drug_name": "0.5 ML Ganirelix acetate 0.5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855288", "drug_name": "Warfarin Sodium 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855290", "drug_name": "Warfarin Sodium 1 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855292", "drug_name": "Warfarin Sodium 1 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855296", "drug_name": "Warfarin Sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855298", "drug_name": "Warfarin Sodium 10 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855300", "drug_name": "Warfarin Sodium 10 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855302", "drug_name": "Warfarin Sodium 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855304", "drug_name": "Warfarin Sodium 2 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855306", "drug_name": "Warfarin Sodium 2 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855312", "drug_name": "Warfarin Sodium 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855314", "drug_name": "Warfarin Sodium 2.5 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855316", "drug_name": "Warfarin Sodium 2.5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855318", "drug_name": "Warfarin Sodium 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855320", "drug_name": "Warfarin Sodium 3 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855322", "drug_name": "Warfarin Sodium 3 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855324", "drug_name": "Warfarin Sodium 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855326", "drug_name": "Warfarin Sodium 4 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855328", "drug_name": "Warfarin Sodium 4 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855332", "drug_name": "Warfarin Sodium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855334", "drug_name": "Warfarin Sodium 5 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855336", "drug_name": "Warfarin Sodium 5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855338", "drug_name": "Warfarin Sodium 6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855340", "drug_name": "Warfarin Sodium 6 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855342", "drug_name": "Warfarin Sodium 6 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855344", "drug_name": "Warfarin Sodium 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855346", "drug_name": "Warfarin Sodium 7.5 MG Oral Tablet [Coumadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855348", "drug_name": "Warfarin Sodium 7.5 MG Oral Tablet [Jantoven]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855474", "drug_name": "alclometasone dipropionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855480", "drug_name": "alclometasone dipropionate 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855626", "drug_name": "Twice-Daily diclofenac epolamine 0.013 MG/MG Medicated Patch", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "855628", "drug_name": "Twice-Daily diclofenac epolamine 0.013 MG/MG Medicated Patch [Flector]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "855635", "drug_name": "Diclofenac Sodium 0.01 MG/MG Topical Gel [Voltaren]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "855642", "drug_name": "Diclofenac Sodium 0.03 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855644", "drug_name": "Diclofenac Sodium 0.03 MG/MG Topical Gel [Solaraze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855657", "drug_name": "24 HR Diclofenac Sodium 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855659", "drug_name": "24 HR Diclofenac Sodium 100 MG Extended Release Oral Tablet [Voltaren]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855664", "drug_name": "Diclofenac Sodium 25 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855671", "drug_name": "Phenytoin sodium 100 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855673", "drug_name": "Phenytoin sodium 100 MG Extended Release Oral Capsule [Dilantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855812", "drug_name": "prasugrel 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855816", "drug_name": "prasugrel 10 MG Oral Tablet [Effient]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855818", "drug_name": "prasugrel 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855820", "drug_name": "prasugrel 5 MG Oral Tablet [Effient]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855858", "drug_name": "3 ML Apomorphine hydrochloride 10 MG/ML Cartridge [Apokyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855861", "drug_name": "Phenytoin sodium 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855863", "drug_name": "Phenytoin sodium 200 MG Extended Release Oral Capsule [Phenytek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855871", "drug_name": "Phenytoin sodium 30 MG Extended Release Oral Capsule [Dilantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855873", "drug_name": "Phenytoin sodium 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855875", "drug_name": "Phenytoin sodium 300 MG Extended Release Oral Capsule [Phenytek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855906", "drug_name": "Diclofenac Sodium 50 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855926", "drug_name": "Diclofenac Sodium 75 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "855942", "drug_name": "Diclofenac Potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856364", "drug_name": "Trazodone Hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856369", "drug_name": "Trazodone Hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856373", "drug_name": "Trazodone Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856377", "drug_name": "Trazodone Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856422", "drug_name": "Hydrochlorothiazide 25 MG / Propranolol Hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856429", "drug_name": "Hydrochlorothiazide 25 MG / Propranolol Hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856448", "drug_name": "Propranolol Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856457", "drug_name": "Propranolol Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856460", "drug_name": "24 HR Propranolol Hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856462", "drug_name": "24 HR Propranolol Hydrochloride 120 MG Extended Release Oral Capsule [Inderal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856471", "drug_name": "24 HR Propranolol Hydrochloride 120 MG Extended Release Oral Capsule [InnoPran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856481", "drug_name": "24 HR Propranolol Hydrochloride 160 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856483", "drug_name": "24 HR Propranolol Hydrochloride 160 MG Extended Release Oral Capsule [Inderal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856519", "drug_name": "Propranolol Hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856535", "drug_name": "24 HR Propranolol Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856537", "drug_name": "24 HR Propranolol Hydrochloride 60 MG Extended Release Oral Capsule [Inderal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856556", "drug_name": "Propranolol Hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856562", "drug_name": "Delavirdine Mesylate 100 MG Oral Tablet [Rescriptor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856569", "drug_name": "24 HR Propranolol Hydrochloride 80 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856571", "drug_name": "24 HR Propranolol Hydrochloride 80 MG Extended Release Oral Capsule [Inderal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856576", "drug_name": "24 HR Propranolol Hydrochloride 80 MG Extended Release Oral Capsule [InnoPran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856578", "drug_name": "Propranolol Hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856605", "drug_name": "Rimantadine Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856607", "drug_name": "Rimantadine Hydrochloride 100 MG Oral Tablet [Flumadine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856612", "drug_name": "Delavirdine Mesylate 200 MG Oral Tablet [Rescriptor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856652", "drug_name": "Dantrolene Sodium 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856656", "drug_name": "Dantrolene Sodium 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856658", "drug_name": "Dantrolene Sodium 25 MG Oral Capsule [Dantrium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856660", "drug_name": "Dantrolene Sodium 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856662", "drug_name": "Dantrolene Sodium 50 MG Oral Capsule [Dantrium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856666", "drug_name": "rifaximin 550 MG Oral Tablet [XIFAXAN]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856706", "drug_name": "Amitriptyline Hydrochloride 10 MG / Perphenazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856720", "drug_name": "Amitriptyline Hydrochloride 10 MG / Perphenazine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856724", "drug_name": "Propranolol Hydrochloride 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856733", "drug_name": "Propranolol Hydrochloride 8 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856762", "drug_name": "Amitriptyline Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856769", "drug_name": "Amitriptyline Hydrochloride 12.5 MG / Chlordiazepoxide 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856773", "drug_name": "Amitriptyline Hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856783", "drug_name": "Amitriptyline Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856789", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Jet Injector [Sumavel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856792", "drug_name": "Amitriptyline Hydrochloride 25 MG / Chlordiazepoxide 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856797", "drug_name": "Amitriptyline Hydrochloride 25 MG / Perphenazine 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856825", "drug_name": "Amitriptyline Hydrochloride 25 MG / Perphenazine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856834", "drug_name": "Amitriptyline Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856840", "drug_name": "Amitriptyline Hydrochloride 50 MG / Perphenazine 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856845", "drug_name": "Amitriptyline Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856853", "drug_name": "Amitriptyline Hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856935", "drug_name": "Fluorometholone 0.001 MG/MG Ophthalmic Ointment [FML]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856944", "drug_name": "Acetaminophen 21.7 MG/ML / Hydrocodone Bitartrate 0.67 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856946", "drug_name": "Acetaminophen 21.7 MG/ML / Hydrocodone Bitartrate 0.67 MG/ML Oral Solution [Zamicet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856980", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "856984", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 10 MG Oral Tablet [Xodol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856987", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856991", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Xodol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856996", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 7.5 MG Oral Tablet [Xodol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "856999", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857001", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 10 MG Oral Tablet [Norco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857002", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857004", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Norco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857005", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857007", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 7.5 MG Oral Tablet [Norco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857166", "drug_name": "Fosinopril Sodium 10 MG / Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857169", "drug_name": "Fosinopril Sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857174", "drug_name": "Fosinopril Sodium 20 MG / Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857183", "drug_name": "Fosinopril Sodium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857187", "drug_name": "Fosinopril Sodium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857218", "drug_name": "Sevelamer hydrochloride 400 MG Oral Tablet [RenaGel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857226", "drug_name": "Sevelamer hydrochloride 800 MG Oral Tablet [RenaGel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857297", "drug_name": "Clomipramine Hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857299", "drug_name": "Clomipramine Hydrochloride 25 MG Oral Capsule [Anafranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857301", "drug_name": "Clomipramine Hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857303", "drug_name": "Clomipramine Hydrochloride 50 MG Oral Capsule [Anafranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857305", "drug_name": "Clomipramine Hydrochloride 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857307", "drug_name": "Clomipramine Hydrochloride 75 MG Oral Capsule [Anafranil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857321", "drug_name": "Bethanechol Chloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857325", "drug_name": "Bethanechol Chloride 10 MG Oral Tablet [Urecholine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857328", "drug_name": "Bethanechol Chloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857332", "drug_name": "Bethanechol Chloride 25 MG Oral Tablet [Urecholine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857336", "drug_name": "Bethanechol Chloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857338", "drug_name": "Bethanechol Chloride 5 MG Oral Tablet [Urecholine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857340", "drug_name": "Bethanechol Chloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857344", "drug_name": "Bethanechol Chloride 50 MG Oral Tablet [Urecholine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857366", "drug_name": "Econazole Nitrate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857391", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857416", "drug_name": "Clemastine Fumarate 1.34 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857461", "drug_name": "Clemastine Fumarate 2.68 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857560", "drug_name": "trospium chloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857677", "drug_name": "Terbutaline Sulfate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857683", "drug_name": "Terbutaline Sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "857700", "drug_name": "Diclofenac Sodium 15 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "857799", "drug_name": "Treprostinil 0.6 MG/ML Inhalation Solution [Tyvaso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858040", "drug_name": "saxagliptin 5 MG Oral Tablet [Onglyza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858044", "drug_name": "saxagliptin 2.5 MG Oral Tablet [Onglyza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858064", "drug_name": "24 HR Minocycline 115 MG Extended Release Oral Tablet [Solodyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858071", "drug_name": "Colchicine 0.6 MG Oral Tablet [Colcrys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858079", "drug_name": "Levonorgestrel 1.5 MG Oral Tablet [Plan B One-Step]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858108", "drug_name": "Testosterone 30 MG Buccal Film [Striant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858116", "drug_name": "Fenoprofen 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858118", "drug_name": "Fenoprofen 400 MG Oral Capsule [Nalfon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858125", "drug_name": "degarelix 80 MG Injection [Firmagon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858127", "drug_name": "degarelix 120 MG Injection [Firmagon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858264", "drug_name": "Doxercalciferol 0.001 MG Oral Capsule [Hectorol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858346", "drug_name": "Diclofenac Potassium 25 MG Oral Capsule [Zipsor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858366", "drug_name": "Ketorolac Tromethamine 4.5 MG/ML Ophthalmic Solution [Acuvail]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858370", "drug_name": "Aloe Polysaccharide 0.01 MG/MG / Iodoquinol 0.0125 MG/MG Topical Gel [Aloquin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858374", "drug_name": "24 HR Minocycline 65 MG Extended Release Oral Tablet [Solodyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858613", "drug_name": "Nicardipine hydrochloride 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858616", "drug_name": "Nicardipine hydrochloride 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858627", "drug_name": "Pramipexole dihydrochloride 0.75 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858733", "drug_name": "Ursodiol 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858735", "drug_name": "Ursodiol 500 MG Oral Tablet [Urso Forte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858747", "drug_name": "Ursodiol 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858749", "drug_name": "Ursodiol 300 MG Oral Capsule [Actigall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858751", "drug_name": "Ursodiol 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858752", "drug_name": "Ursodiol 250 MG Oral Tablet [Urso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858778", "drug_name": "Hydrocodone Bitartrate 5 MG / Ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858780", "drug_name": "Hydrocodone Bitartrate 5 MG / Ibuprofen 200 MG Oral Tablet [Ibudone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858784", "drug_name": "Hydrocodone Bitartrate 5 MG / Ibuprofen 200 MG Oral Tablet [Reprexain]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858798", "drug_name": "Hydrocodone Bitartrate 7.5 MG / Ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "858804", "drug_name": "Enalapril Maleate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858806", "drug_name": "Enalapril Maleate 2.5 MG Oral Tablet [Vasotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858810", "drug_name": "Enalapril Maleate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858812", "drug_name": "Enalapril Maleate 20 MG Oral Tablet [Vasotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858813", "drug_name": "Enalapril Maleate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858815", "drug_name": "Enalapril Maleate 5 MG Oral Tablet [Vasotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858817", "drug_name": "Enalapril Maleate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858819", "drug_name": "Enalapril Maleate 10 MG Oral Tablet [Vasotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858824", "drug_name": "Enalapril Maleate 5 MG / Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858828", "drug_name": "Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "858830", "drug_name": "Enalapril Maleate 10 MG / Hydrochlorothiazide 25 MG Oral Tablet [Vaseretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859033", "drug_name": "Pramipexole dihydrochloride 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859035", "drug_name": "Pramipexole dihydrochloride 0.125 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859040", "drug_name": "Pramipexole dihydrochloride 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859042", "drug_name": "Pramipexole dihydrochloride 0.25 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859044", "drug_name": "Pramipexole dihydrochloride 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859046", "drug_name": "Pramipexole dihydrochloride 0.5 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859048", "drug_name": "Pramipexole dihydrochloride 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859050", "drug_name": "Pramipexole dihydrochloride 1.5 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859052", "drug_name": "Pramipexole dihydrochloride 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859054", "drug_name": "Pramipexole dihydrochloride 1 MG Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859066", "drug_name": "Diclofenac Potassium 50 MG Powder for Oral Solution [Cambia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859081", "drug_name": "Bromocriptine 0.8 MG Oral Tablet [Cycloset]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859088", "drug_name": "NDA020983 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [Ventolin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859126", "drug_name": "Alprostadil 0.125 MG Urethral Suppository [Muse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859128", "drug_name": "Alprostadil 1 MG Urethral Suppository [Muse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859130", "drug_name": "Alprostadil 0.25 MG Urethral Suppository [Muse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859132", "drug_name": "Alprostadil 0.5 MG Urethral Suppository [Muse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859186", "drug_name": "selegiline hydrochloride 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859192", "drug_name": "selegiline hydrochloride 1.25 MG Disintegrating Oral Tablet [Zelapar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859193", "drug_name": "selegiline hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859315", "drug_name": "Hydrocodone Bitartrate 10 MG / Ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859317", "drug_name": "Hydrocodone Bitartrate 10 MG / Ibuprofen 200 MG Oral Tablet [Ibudone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859331", "drug_name": "Hydrocodone Bitartrate 10 MG / Ibuprofen 200 MG Oral Tablet [Reprexain]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859383", "drug_name": "Guaifenesin 40 MG/ML / Hydrocodone Bitartrate 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859419", "drug_name": "Rosuvastatin calcium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859421", "drug_name": "Rosuvastatin calcium 40 MG Oral Tablet [Crestor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859424", "drug_name": "Rosuvastatin calcium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859426", "drug_name": "Rosuvastatin calcium 5 MG Oral Tablet [Crestor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859747", "drug_name": "Rosuvastatin calcium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859749", "drug_name": "Rosuvastatin calcium 10 MG Oral Tablet [Crestor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859751", "drug_name": "Rosuvastatin calcium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859753", "drug_name": "Rosuvastatin calcium 20 MG Oral Tablet [Crestor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859824", "drug_name": "fluphenazine decanoate 25 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859835", "drug_name": "Fluphenazine Hydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859841", "drug_name": "Fluphenazine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859861", "drug_name": "Saquinavir 200 MG Oral Capsule [Invirase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859865", "drug_name": "saquinavir mesylate 500 MG Oral Tablet [Invirase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859867", "drug_name": "haloperidol decanoate 50 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859871", "drug_name": "haloperidol decanoate 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "859979", "drug_name": "Asenapine 10 MG Sublingual Tablet [Saphris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "859983", "drug_name": "Asenapine 5 MG Sublingual Tablet [Saphris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "860088", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Cartridge [Imitrex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "860103", "drug_name": "Ketorolac Tromethamine 4 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860105", "drug_name": "Ketorolac Tromethamine 4 MG/ML Ophthalmic Solution [Acular]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860107", "drug_name": "Ketorolac Tromethamine 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860109", "drug_name": "Ketorolac Tromethamine 5 MG/ML Ophthalmic Solution [Acular]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860215", "drug_name": "Megestrol Acetate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860221", "drug_name": "Megestrol Acetate 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860225", "drug_name": "Megestrol Acetate 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860227", "drug_name": "Megestrol Acetate 40 MG/ML Oral Suspension [Megace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860244", "drug_name": "interferon beta-1b 0.3 MG Injection [Extavia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860510", "drug_name": "24 HR carvedilol phosphate 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860512", "drug_name": "24 HR carvedilol phosphate 10 MG Extended Release Oral Capsule [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860516", "drug_name": "24 HR carvedilol phosphate 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860518", "drug_name": "24 HR carvedilol phosphate 20 MG Extended Release Oral Capsule [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860522", "drug_name": "24 HR carvedilol phosphate 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860524", "drug_name": "24 HR carvedilol phosphate 40 MG Extended Release Oral Capsule [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860532", "drug_name": "24 HR carvedilol phosphate 80 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860534", "drug_name": "24 HR carvedilol phosphate 80 MG Extended Release Oral Capsule [Coreg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860656", "drug_name": "epinastine hydrochloride 0.5 MG/ML Ophthalmic Solution [Elestat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860695", "drug_name": "24 HR galantamine hydrobromide 16 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860697", "drug_name": "24 HR galantamine hydrobromide 16 MG Extended Release Oral Capsule [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860707", "drug_name": "24 HR galantamine hydrobromide 24 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860709", "drug_name": "24 HR galantamine hydrobromide 24 MG Extended Release Oral Capsule [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860715", "drug_name": "24 HR galantamine hydrobromide 8 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860717", "drug_name": "24 HR galantamine hydrobromide 8 MG Extended Release Oral Capsule [Razadyne]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860737", "drug_name": "12 HR ranolazine 1000 MG Extended Release Oral Tablet [Ranexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860738", "drug_name": "12 HR ranolazine 500 MG Extended Release Oral Tablet [Ranexa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860771", "drug_name": "Trimethobenzamide hydrochloride 300 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860773", "drug_name": "Trimethobenzamide hydrochloride 300 MG Oral Capsule [Tigan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860796", "drug_name": "200 ACTUAT Azelastine hydrochloride 0.137 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860805", "drug_name": "Azelastine hydrochloride 0.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860880", "drug_name": "fenofibric acid 105 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860884", "drug_name": "fenofibric acid 105 MG Oral Tablet [Fibricor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860886", "drug_name": "fenofibric acid 35 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860888", "drug_name": "fenofibric acid 35 MG Oral Tablet [Fibricor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860895", "drug_name": "Vigabatrin 500 MG Oral Tablet [Sabril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860898", "drug_name": "Vigabatrin 500 MG Powder for Oral Solution [Sabril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860901", "drug_name": "galantamine hydrobromide 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860918", "drug_name": "Fluphenazine Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860975", "drug_name": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860977", "drug_name": "24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet [Glucophage]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860981", "drug_name": "24 HR Metformin hydrochloride 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860983", "drug_name": "24 HR Metformin hydrochloride 750 MG Extended Release Oral Tablet [Glucophage]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860996", "drug_name": "24 HR Metformin hydrochloride 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "860998", "drug_name": "Osmotic 24 HR Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Fortamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861002", "drug_name": "Osmotic 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet [Fortamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861004", "drug_name": "Metformin hydrochloride 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861006", "drug_name": "Metformin hydrochloride 1000 MG Oral Tablet [Glucophage]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861007", "drug_name": "Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861008", "drug_name": "Metformin hydrochloride 500 MG Oral Tablet [Glucophage]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861010", "drug_name": "Metformin hydrochloride 850 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861012", "drug_name": "Metformin hydrochloride 850 MG Oral Tablet [Glucophage]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861015", "drug_name": "Modified 24 HR Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Glumetza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861018", "drug_name": "Modified 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet [Glumetza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861025", "drug_name": "Metformin hydrochloride 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861027", "drug_name": "Metformin hydrochloride 100 MG/ML Oral Solution [Riomet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861043", "drug_name": "2.7 ML pramlintide acetate 1 MG/ML Pen Injector [Symlin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861045", "drug_name": "1.5 ML pramlintide acetate 1 MG/ML Pen Injector [Symlin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861061", "drug_name": "Doxycycline Monohydrate 5 MG/ML Oral Suspension [Vibramycin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861064", "drug_name": "Sertraline 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861066", "drug_name": "Sertraline 20 MG/ML Oral Solution [Zoloft]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861072", "drug_name": "Ascorbic Acid 500 MG / ferrous sulfate 525 MG / Folic Acid 0.8 MG Extended Release Oral Tablet [Folitab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861083", "drug_name": "folic acid 1 MG / polysaccharide iron complex 150 MG / vitamin B12 0.025 MG Oral Capsule [Ferrex 150 Forte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861115", "drug_name": "vitamin B12 0.5 MG/ACTUAT Nasal Spray [Nascobal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861132", "drug_name": "24 HR Alfuzosin hydrochloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861134", "drug_name": "24 HR Alfuzosin hydrochloride 10 MG Extended Release Oral Tablet [UroXatral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861159", "drug_name": "12 HR Propafenone Hydrochloride 225 MG Extended Release Oral Capsule [Rythmol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861167", "drug_name": "12 HR Propafenone Hydrochloride 325 MG Extended Release Oral Capsule [Rythmol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861173", "drug_name": "12 HR Propafenone Hydrochloride 425 MG Extended Release Oral Capsule [Rythmol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861200", "drug_name": "Brimonidine tartrate 2 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861206", "drug_name": "Brimonidine tartrate 1 MG/ML Ophthalmic Solution [Alphagan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861208", "drug_name": "Brimonidine tartrate 1.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861210", "drug_name": "Brimonidine tartrate 1.5 MG/ML Ophthalmic Solution [Alphagan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861221", "drug_name": "24 HR Amphetamine aspartate 2.5 MG / Amphetamine Sulfate 2.5 MG / Dextroamphetamine saccharate 2.5 MG / Dextroamphetamine Sulfate 2.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861222", "drug_name": "24 HR Amphetamine aspartate 2.5 MG / Amphetamine Sulfate 2.5 MG / Dextroamphetamine saccharate 2.5 MG / Dextroamphetamine Sulfate 2.5 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861223", "drug_name": "24 HR Amphetamine aspartate 3.75 MG / Amphetamine Sulfate 3.75 MG / Dextroamphetamine saccharate 3.75 MG / Dextroamphetamine Sulfate 3.75 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861224", "drug_name": "24 HR Amphetamine aspartate 3.75 MG / Amphetamine Sulfate 3.75 MG / Dextroamphetamine saccharate 3.75 MG / Dextroamphetamine Sulfate 3.75 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861225", "drug_name": "24 HR Amphetamine aspartate 5 MG / Amphetamine Sulfate 5 MG / Dextroamphetamine saccharate 5 MG / Dextroamphetamine Sulfate 5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861226", "drug_name": "24 HR Amphetamine aspartate 5 MG / Amphetamine Sulfate 5 MG / Dextroamphetamine saccharate 5 MG / Dextroamphetamine Sulfate 5 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861227", "drug_name": "24 HR Amphetamine aspartate 6.25 MG / Amphetamine Sulfate 6.25 MG / Dextroamphetamine saccharate 6.25 MG / Dextroamphetamine Sulfate 6.25 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861228", "drug_name": "24 HR Amphetamine aspartate 6.25 MG / Amphetamine Sulfate 6.25 MG / Dextroamphetamine saccharate 6.25 MG / Dextroamphetamine Sulfate 6.25 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861232", "drug_name": "24 HR Amphetamine aspartate 7.5 MG / Amphetamine Sulfate 7.5 MG / Dextroamphetamine saccharate 7.5 MG / Dextroamphetamine Sulfate 7.5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861233", "drug_name": "24 HR Amphetamine aspartate 7.5 MG / Amphetamine Sulfate 7.5 MG / Dextroamphetamine saccharate 7.5 MG / Dextroamphetamine Sulfate 7.5 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861237", "drug_name": "24 HR Amphetamine aspartate 1.25 MG / Amphetamine Sulfate 1.25 MG / Dextroamphetamine saccharate 1.25 MG / Dextroamphetamine Sulfate 1.25 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861238", "drug_name": "24 HR Amphetamine aspartate 1.25 MG / Amphetamine Sulfate 1.25 MG / Dextroamphetamine saccharate 1.25 MG / Dextroamphetamine Sulfate 1.25 MG Extended Release Oral Capsule [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861353", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861355", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Foam [Olux]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861356", "drug_name": "0.8 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861358", "drug_name": "0.8 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe [Arixtra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861360", "drug_name": "0.5 ML Fondaparinux sodium 5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861362", "drug_name": "0.5 ML Fondaparinux sodium 5 MG/ML Prefilled Syringe [Arixtra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861363", "drug_name": "0.4 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861364", "drug_name": "0.4 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe [Arixtra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861365", "drug_name": "0.6 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861366", "drug_name": "0.6 ML Fondaparinux sodium 12.5 MG/ML Prefilled Syringe [Arixtra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861370", "drug_name": "sevelamer carbonate 2400 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861373", "drug_name": "sevelamer carbonate 2400 MG Powder for Oral Suspension [Renvela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861375", "drug_name": "sevelamer carbonate 800 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861377", "drug_name": "sevelamer carbonate 800 MG Powder for Oral Suspension [Renvela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861402", "drug_name": "Phenoxybenzamine Hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861404", "drug_name": "Phenoxybenzamine Hydrochloride 10 MG Oral Capsule [Dibenzyline]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861416", "drug_name": "Azithromycin 1000 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861417", "drug_name": "Azithromycin 1000 MG Powder for Oral Suspension [Zithromax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861420", "drug_name": "Timolol 0.0025 MG/MG Ophthalmic Gel [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861422", "drug_name": "Timolol 0.005 MG/MG Ophthalmic Gel [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861424", "drug_name": "Propafenone Hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861427", "drug_name": "Propafenone Hydrochloride 225 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861428", "drug_name": "Propafenone Hydrochloride 225 MG Oral Tablet [Rythmol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861430", "drug_name": "Propafenone Hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861434", "drug_name": "Clobetasol Propionate 0.0005 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861448", "drug_name": "Clobetasol Propionate 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861455", "drug_name": "Meperidine Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861467", "drug_name": "Meperidine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861472", "drug_name": "Clobetasol Propionate 0.0005 MG/MG Topical Ointment [Temovate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861476", "drug_name": "1 ML Meperidine Hydrochloride 25 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861479", "drug_name": "Meperidine Hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861487", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861492", "drug_name": "Clobetasol Propionate 0.5 MG/ML Medicated Shampoo [Clobex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861495", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861503", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Cream [Temovate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861506", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Lotion [Clobex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861512", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861513", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Spray [Clobex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861517", "drug_name": "Meperidine Hydrochloride 100 MG Oral Tablet [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861526", "drug_name": "Clobetasol Propionate 0.5 MG/ML Topical Solution [Cormax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861529", "drug_name": "1 ML Meperidine Hydrochloride 50 MG/ML Cartridge [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861568", "drug_name": "Esomeprazole 10 MG Granules for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861570", "drug_name": "Esomeprazole 10 MG Granules for Oral Suspension [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861576", "drug_name": "Esomeprazole 20 MG Granules for Oral Suspension [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861583", "drug_name": "Esomeprazole 40 MG Granules for Oral Suspension [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861597", "drug_name": "Pentamidine Isethionate 50 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861599", "drug_name": "Pentamidine Isethionate 50 MG/ML Inhalation Solution [NebuPent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861617", "drug_name": "1 ML Meperidine Hydrochloride 75 MG/ML Cartridge [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861637", "drug_name": "Brimonidine tartrate 2 MG/ML / Timolol 5 MG/ML Ophthalmic Solution [Combigan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861646", "drug_name": "pitavastatin calcium 1 MG Oral Tablet [Livalo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861650", "drug_name": "pitavastatin calcium 2 MG Oral Tablet [Livalo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861654", "drug_name": "pitavastatin calcium 4 MG Oral Tablet [Livalo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861657", "drug_name": "24 HR Nitroglycerin 0.1 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861659", "drug_name": "24 HR Nitroglycerin 0.1 MG/HR Transdermal System [Minitran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861661", "drug_name": "24 HR Nitroglycerin 0.2 MG/HR Transdermal System [Minitran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861663", "drug_name": "24 HR Nitroglycerin 0.4 MG/HR Transdermal System [Minitran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861668", "drug_name": "Dihydroergotamine Mesylate 0.5 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861670", "drug_name": "Dihydroergotamine Mesylate 0.5 MG/ACTUAT Metered Dose Nasal Spray [Migranal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861672", "drug_name": "1 ML Dihydroergotamine Mesylate 1 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861674", "drug_name": "1 ML Dihydroergotamine Mesylate 1 MG/ML Injection [DHE-45]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861689", "drug_name": "12 HR Amoxicillin 1000 MG / Clavulanate 62.5 MG Extended Release Oral Tablet [Augmentin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861717", "drug_name": "Sodium Fluoride 0.917 MG/ML Oral Solution [Fluorabon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861724", "drug_name": "Sodium Fluoride 1.1 MG Chewable Tablet [Fluoritab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861731", "drug_name": "Glipizide 2.5 MG / Metformin hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861736", "drug_name": "Glipizide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861740", "drug_name": "Glipizide 5 MG / Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861743", "drug_name": "Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861748", "drug_name": "Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861752", "drug_name": "Glyburide 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Glucovance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861753", "drug_name": "Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861757", "drug_name": "Glyburide 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Glucovance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861762", "drug_name": "Metformin hydrochloride 1000 MG / rosiglitazone 2 MG Oral Tablet [Avandamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861771", "drug_name": "Metformin hydrochloride 1000 MG / sitagliptin 50 MG Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861783", "drug_name": "Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861785", "drug_name": "Metformin hydrochloride 500 MG / pioglitazone 15 MG Oral Tablet [Actoplus Met]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861787", "drug_name": "Metformin hydrochloride 500 MG / repaglinide 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861790", "drug_name": "Metformin hydrochloride 500 MG / repaglinide 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861808", "drug_name": "Metformin hydrochloride 500 MG / rosiglitazone 2 MG Oral Tablet [Avandamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861821", "drug_name": "Metformin hydrochloride 500 MG / sitagliptin 50 MG Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861822", "drug_name": "Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861824", "drug_name": "Metformin hydrochloride 850 MG / pioglitazone 15 MG Oral Tablet [Actoplus Met]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861830", "drug_name": "amylase 55000 UNT / lipase 10000 UNT / protease 34000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861834", "drug_name": "amylase 82000 UNT / lipase 15000 UNT / protease 51000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861838", "drug_name": "amylase 109000 UNT / lipase 20000 UNT / protease 68000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861842", "drug_name": "amylase 27000 UNT / lipase 5000 UNT / protease 17000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861848", "drug_name": "Fluphenazine Hydrochloride 5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861960", "drug_name": "armodafinil 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "861962", "drug_name": "armodafinil 200 MG Oral Tablet [Nuvigil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "861966", "drug_name": "Iloprost 0.02 MG/ML Inhalation Solution [Ventavis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862006", "drug_name": "24 HR Guanfacine 1 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862010", "drug_name": "24 HR Guanfacine 1 MG Extended Release Oral Tablet [Intuniv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862013", "drug_name": "24 HR Guanfacine 2 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862015", "drug_name": "24 HR Guanfacine 2 MG Extended Release Oral Tablet [Intuniv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862019", "drug_name": "24 HR Guanfacine 3 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862021", "drug_name": "24 HR Guanfacine 3 MG Extended Release Oral Tablet [Intuniv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862025", "drug_name": "24 HR Guanfacine 4 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862027", "drug_name": "24 HR Guanfacine 4 MG Extended Release Oral Tablet [Intuniv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "862041", "drug_name": "200 ACTUAT Azelastine hydrochloride 0.206 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "862042", "drug_name": "200 ACTUAT Azelastine hydrochloride 0.206 MG/ACTUAT Nasal Inhaler [Astepro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863042", "drug_name": "bepotastine besilate 15 MG/ML Ophthalmic Solution [Bepreve]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863181", "drug_name": "Anthralin 12 MG/ML Topical Cream [Zithranol-RR]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863562", "drug_name": "valganciclovir 50 MG/ML Oral Solution [Valcyte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863588", "drug_name": "Metoclopramide 5 MG Disintegrating Oral Tablet [Metozolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863599", "drug_name": "Oxybutynin chloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863603", "drug_name": "Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension [E.E.S.]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863606", "drug_name": "Erythromycin Ethylsuccinate 400 MG Oral Tablet [E.E.S.]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863619", "drug_name": "24 HR Oxybutynin chloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863622", "drug_name": "24 HR Oxybutynin chloride 10 MG Extended Release Oral Tablet [Ditropan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863628", "drug_name": "24 HR Oxybutynin chloride 15 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863630", "drug_name": "24 HR Oxybutynin chloride 15 MG Extended Release Oral Tablet [Ditropan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863636", "drug_name": "24 HR Oxybutynin chloride 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863638", "drug_name": "24 HR Oxybutynin chloride 5 MG Extended Release Oral Tablet [Ditropan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863664", "drug_name": "Oxybutynin chloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863669", "drug_name": "Tamsulosin hydrochloride 0.4 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863671", "drug_name": "Tamsulosin hydrochloride 0.4 MG Oral Capsule [Flomax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863829", "drug_name": "amylase 120000 UNT / lipase 24000 UNT / protease 76000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863836", "drug_name": "amylase 30000 UNT / lipase 6000 UNT / protease 19000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "863841", "drug_name": "amylase 60000 UNT / lipase 12000 UNT / protease 38000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "864110", "drug_name": "1.5 ML Somatropin 3.3 MG/ML Cartridge [Omnitrope]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "864661", "drug_name": "efavirenz 600 MG / Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864679", "drug_name": "Atovaquone 250 MG / proguanil hydrochloride 100 MG Oral Tablet [Malarone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "864685", "drug_name": "Atovaquone 62.5 MG / proguanil hydrochloride 25 MG Oral Tablet [Malarone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "864706", "drug_name": "Methadone Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864708", "drug_name": "Methadone Hydrochloride 10 MG Oral Tablet [Dolophine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864714", "drug_name": "Methadone Hydrochloride 10 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "864718", "drug_name": "Methadone Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864720", "drug_name": "Methadone Hydrochloride 5 MG Oral Tablet [Dolophine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864761", "drug_name": "Methadone Hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864769", "drug_name": "Methadone Hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864820", "drug_name": "Oxybutynin chloride 0.1 MG/MG Topical Gel [Gelnique]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864978", "drug_name": "Methadone Hydrochloride 40 MG Tablet for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "864980", "drug_name": "Methadone Hydrochloride 40 MG Tablet for Oral Suspension [Methadose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "865098", "drug_name": "Insulin Lispro 100 UNT/ML Injectable Solution [Humalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865117", "drug_name": "Fluphenazine Hydrochloride 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865123", "drug_name": "Fluphenazine Hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865129", "drug_name": "Fluphenazine Hydrochloride 2.5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865208", "drug_name": "24 HR Selegiline 0.25 MG/HR Transdermal System [Emsam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865212", "drug_name": "24 HR Selegiline 0.375 MG/HR Transdermal System [Emsam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865216", "drug_name": "24 HR Selegiline 0.5 MG/HR Transdermal System [Emsam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865568", "drug_name": "24 HR Glipizide 10 MG Extended Release Oral Tablet [Glucotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865571", "drug_name": "24 HR Glipizide 2.5 MG Extended Release Oral Tablet [Glucotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "865573", "drug_name": "24 HR Glipizide 5 MG Extended Release Oral Tablet [Glucotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866018", "drug_name": "buspirone hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866021", "drug_name": "Cyproheptadine hydrochloride 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866042", "drug_name": "Neomycin Sulfate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866047", "drug_name": "28 ACTUAT salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Serevent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866049", "drug_name": "60 ACTUAT salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Serevent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866054", "drug_name": "Benzoyl Peroxide 53 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866058", "drug_name": "Benzoyl Peroxide 53 MG/ML Topical Foam [Benzefoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866083", "drug_name": "buspirone hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866090", "drug_name": "buspirone hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866094", "drug_name": "buspirone hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866103", "drug_name": "24 HR paliperidone 1.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "866105", "drug_name": "24 HR paliperidone 1.5 MG Extended Release Oral Tablet [Invega]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "866111", "drug_name": "buspirone hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866144", "drug_name": "Cyproheptadine hydrochloride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866152", "drug_name": "lansoprazole 30 MG Disintegrating Oral Tablet [Prevacid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "866303", "drug_name": "12 HR Carbamazepine 100 MG Extended Release Oral Tablet [Tegretol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866305", "drug_name": "12 HR Carbamazepine 200 MG Extended Release Oral Tablet [Tegretol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866307", "drug_name": "12 HR Carbamazepine 400 MG Extended Release Oral Tablet [Tegretol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866412", "drug_name": "24 HR metoprolol succinate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866414", "drug_name": "24 HR metoprolol succinate 100 MG Extended Release Oral Tablet [Toprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866419", "drug_name": "24 HR metoprolol succinate 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866421", "drug_name": "24 HR metoprolol succinate 200 MG Extended Release Oral Tablet [Toprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866427", "drug_name": "24 HR metoprolol succinate 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866429", "drug_name": "24 HR metoprolol succinate 25 MG Extended Release Oral Tablet [Toprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866436", "drug_name": "24 HR metoprolol succinate 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866438", "drug_name": "24 HR metoprolol succinate 50 MG Extended Release Oral Tablet [Toprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866452", "drug_name": "24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866455", "drug_name": "24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 100 MG Extended Release Oral Tablet [Dutoprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866464", "drug_name": "24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 25 MG Extended Release Oral Tablet [Dutoprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866472", "drug_name": "24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866475", "drug_name": "24 HR Hydrochlorothiazide 12.5 MG / metoprolol succinate 50 MG Extended Release Oral Tablet [Dutoprol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866479", "drug_name": "Hydrochlorothiazide 25 MG / Metoprolol Tartrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866482", "drug_name": "Hydrochlorothiazide 25 MG / Metoprolol Tartrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866491", "drug_name": "Hydrochlorothiazide 50 MG / Metoprolol Tartrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866502", "drug_name": "Hydrochlorothiazide 25 MG / Metoprolol Tartrate 50 MG Oral Tablet [Lopressor HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866511", "drug_name": "Metoprolol Tartrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866513", "drug_name": "Metoprolol Tartrate 100 MG Oral Tablet [Lopressor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866514", "drug_name": "Metoprolol Tartrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866516", "drug_name": "Metoprolol Tartrate 50 MG Oral Tablet [Lopressor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866905", "drug_name": "Colesevelam hydrochloride 3750 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866907", "drug_name": "Colesevelam hydrochloride 3750 MG Powder for Oral Suspension [Welchol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866910", "drug_name": "Colesevelam hydrochloride 625 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866912", "drug_name": "Colesevelam hydrochloride 625 MG Oral Tablet [Welchol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "866924", "drug_name": "Metoprolol Tartrate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "867381", "drug_name": "C1 esterase inhibitor (human) 500 UNT Injection [Berinert]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "867506", "drug_name": "pazopanib 200 MG Oral Tablet [Votrient]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "876193", "drug_name": "POLYETHYLENE GLYCOL 3350 17000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876439", "drug_name": "12 HR Acetazolamide 500 MG Extended Release Oral Capsule [Diamox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876514", "drug_name": "Amlodipine 10 MG / telmisartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876518", "drug_name": "Amlodipine 10 MG / telmisartan 40 MG Oral Tablet [Twynsta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876519", "drug_name": "Amlodipine 10 MG / telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876523", "drug_name": "Amlodipine 10 MG / telmisartan 80 MG Oral Tablet [Twynsta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876524", "drug_name": "Amlodipine 5 MG / telmisartan 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876528", "drug_name": "Amlodipine 5 MG / telmisartan 40 MG Oral Tablet [Twynsta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876529", "drug_name": "Amlodipine 5 MG / telmisartan 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876533", "drug_name": "Amlodipine 5 MG / telmisartan 80 MG Oral Tablet [Twynsta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876553", "drug_name": "Acetylcholine Chloride 10 MG/ML Ophthalmic Solution [Miochol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876690", "drug_name": "Ondansetron 4 MG Disintegrating Oral Tablet [Zofran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "876693", "drug_name": "Ondansetron 8 MG Disintegrating Oral Tablet [Zofran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "877417", "drug_name": "Chenodeoxycholate 250 MG Oral Tablet [Chenodal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "880945", "drug_name": "folic acid 2.2 MG / vitamin B12 1 MG / vitamin B6 25 MG Oral Tablet [TL Gard Rx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "881343", "drug_name": "adefovir dipivoxil 10 MG Oral Tablet [Hepsera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "881350", "drug_name": "Hydrocortisone 20 MG/ML Topical Lotion [Pediaderm HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "881407", "drug_name": "Glyburide 1.5 MG Oral Tablet [Glynase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "881409", "drug_name": "Glyburide 3 MG Oral Tablet [Glynase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "881411", "drug_name": "Glyburide 6 MG Oral Tablet [Glynase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "882530", "drug_name": "12.5 ML sildenafil 0.8 MG/ML Injection [Revatio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "882533", "drug_name": "Clindamycin 100 MG Vaginal Insert [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "882536", "drug_name": "Clindamycin 20 MG/ML Vaginal Cream [Cleocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "882550", "drug_name": "clindamycin phosphate 0.012 MG/MG / Tretinoin 0.00025 MG/MG Topical Gel [Ziana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "882559", "drug_name": "Hydrochlorothiazide 25 MG / quinapril 20 MG Oral Tablet [Accuretic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "883358", "drug_name": "Calcitriol 0.000003 MG/MG Topical Ointment [Vectical]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "883501", "drug_name": "Keralyt 6 % Scalp Complete Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "883826", "drug_name": "Tranexamic Acid 650 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "883830", "drug_name": "Tranexamic Acid 650 MG Oral Tablet [Lysteda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884077", "drug_name": "Hydrocortisone 20 MG/ML Topical Lotion [Ala-Scalp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884173", "drug_name": "Clonidine Hydrochloride 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884175", "drug_name": "Clonidine Hydrochloride 0.1 MG Oral Tablet [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884185", "drug_name": "Clonidine Hydrochloride 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884187", "drug_name": "Clonidine Hydrochloride 0.2 MG Oral Tablet [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884189", "drug_name": "Clonidine Hydrochloride 0.3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884191", "drug_name": "Clonidine Hydrochloride 0.3 MG Oral Tablet [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884308", "drug_name": "Nystatin 100 UNT/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884383", "drug_name": "24 HR Lovastatin 60 MG Extended Release Oral Tablet [Altoprev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884385", "drug_name": "Dextroamphetamine Sulfate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884386", "drug_name": "Dextroamphetamine Sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884520", "drug_name": "Dextroamphetamine Sulfate 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884526", "drug_name": "Dextroamphetamine Sulfate 1 MG/ML Oral Solution [ProCentra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884528", "drug_name": "Dextroamphetamine Sulfate 10 MG Extended Release Oral Capsule [Dexedrine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884532", "drug_name": "Dextroamphetamine Sulfate 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884534", "drug_name": "Dextroamphetamine Sulfate 15 MG Extended Release Oral Capsule [Dexedrine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884535", "drug_name": "Dextroamphetamine Sulfate 5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884537", "drug_name": "Dextroamphetamine Sulfate 5 MG Extended Release Oral Capsule [Dexedrine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884619", "drug_name": "eltrombopag 75 MG Oral Tablet [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "884655", "drug_name": "Amphetamine Sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884707", "drug_name": "Estradiol 0.01 MG Vaginal Insert", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "884709", "drug_name": "Estradiol 0.01 MG Vaginal Insert [Vagifem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885111", "drug_name": "Megestrol Acetate 125 MG/ML Oral Suspension [Megace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885133", "drug_name": "Benzoyl Peroxide 0.025 MG/MG / clindamycin phosphate 0.012 MG/MG Topical Gel [Acanya]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885209", "drug_name": "benztropine mesylate 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885213", "drug_name": "benztropine mesylate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885219", "drug_name": "benztropine mesylate 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885857", "drug_name": "Balsalazide disodium 750 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "885859", "drug_name": "Balsalazide disodium 750 MG Oral Capsule [Colazal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "886634", "drug_name": "Butorphanol Tartrate 1 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "886662", "drug_name": "Flecainide Acetate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "886666", "drug_name": "Flecainide Acetate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "886671", "drug_name": "Flecainide Acetate 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "889614", "drug_name": "Chlordiazepoxide Hydrochloride 5 MG / Clidinium bromide 2.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "889616", "drug_name": "Chlordiazepoxide Hydrochloride 5 MG / Clidinium bromide 2.5 MG Oral Capsule [Librax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "890918", "drug_name": "Estradiol 0.1 MG/ML Vaginal Cream [Estrace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "890923", "drug_name": "5000 MG Clindamycin 20 MG/ML Prefilled Applicator [Clindesse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "891453", "drug_name": "Potassium Chloride 0.167 MEQ/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "891631", "drug_name": "Desoximetasone 0.5 MG/ML Topical Cream [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "891870", "drug_name": "Isosorbide Dinitrate 40 MG Extended Release Oral Capsule [Dilatrate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "891874", "drug_name": "Morphine Sulfate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "891881", "drug_name": "Morphine Sulfate 15 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "891888", "drug_name": "Morphine Sulfate 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "891893", "drug_name": "Morphine Sulfate 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892246", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892251", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892255", "drug_name": "Levothyroxine Sodium 0.3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892473", "drug_name": "10 ML Morphine Sulfate 0.5 MG/ML Injection [Duramorph]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892489", "drug_name": "10 ML Morphine Sulfate 1 MG/ML Injection [Duramorph]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892496", "drug_name": "Morphine Sulfate 10 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892516", "drug_name": "Morphine Sulfate 10 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892531", "drug_name": "Morphine Sulfate 10 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892556", "drug_name": "Morphine Sulfate 100 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892560", "drug_name": "Morphine Sulfate 100 MG Extended Release Oral Tablet [MS Contin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892574", "drug_name": "Morphine Sulfate 15 MG Extended Release Oral Tablet [MS Contin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892582", "drug_name": "Morphine Sulfate 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892589", "drug_name": "Morphine Sulfate 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892598", "drug_name": "Morphine Sulfate 20 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892603", "drug_name": "Morphine Sulfate 20 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892625", "drug_name": "Morphine Sulfate 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892645", "drug_name": "Morphine Sulfate 200 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892646", "drug_name": "Morphine Sulfate 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892648", "drug_name": "Morphine Sulfate 200 MG Extended Release Oral Tablet [MS Contin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892652", "drug_name": "20 ML Morphine Sulfate 25 MG/ML Injection [Infumorph]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "892658", "drug_name": "Morphine Sulfate 30 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892660", "drug_name": "Morphine Sulfate 30 MG Extended Release Oral Tablet [MS Contin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892672", "drug_name": "Morphine Sulfate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "892678", "drug_name": "Morphine Sulfate 30 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894780", "drug_name": "Morphine Sulfate 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894803", "drug_name": "Morphine Sulfate 50 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894805", "drug_name": "Morphine Sulfate 60 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894807", "drug_name": "Morphine Sulfate 5 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894813", "drug_name": "Morphine Sulfate 60 MG Extended Release Oral Tablet [MS Contin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894816", "drug_name": "Morphine Sulfate 80 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "894859", "drug_name": "Acitretin 17.5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "894861", "drug_name": "Acitretin 17.5 MG Oral Capsule [Soriatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "894914", "drug_name": "1 ML Morphine Sulfate 8 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "895194", "drug_name": "Morphine Sulfate 15 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "895487", "drug_name": "Fluticasone propionate 0.00005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "895670", "drug_name": "24 HR quetiapine 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "895671", "drug_name": "24 HR quetiapine 150 MG Extended Release Oral Tablet [Seroquel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "895970", "drug_name": "120 ACTUAT fluticasone furoate 0.0275 MG/ACTUAT Nasal Inhaler [Veramyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "895987", "drug_name": "Fluticasone propionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "895989", "drug_name": "Fluticasone propionate 0.5 MG/ML Topical Cream [Cutivate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "895991", "drug_name": "Fluticasone propionate 0.5 MG/ML Topical Lotion [Cutivate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "895996", "drug_name": "120 ACTUAT Fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896001", "drug_name": "120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896006", "drug_name": "120 ACTUAT Fluticasone propionate 0.22 MG/ACTUAT Metered Dose Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896019", "drug_name": "60 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Dry Powder Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896023", "drug_name": "60 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT Dry Powder Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896027", "drug_name": "60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT Dry Powder Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896031", "drug_name": "28 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT Dry Powder Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896103", "drug_name": "200 ACTUAT Nicotine 0.5 MG/ACTUAT Nasal Inhaler [Nicotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896106", "drug_name": "Naftifine hydrochloride 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896108", "drug_name": "Naftifine hydrochloride 0.01 MG/MG Topical Gel [Naftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896110", "drug_name": "Naftifine hydrochloride 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896161", "drug_name": "14 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896165", "drug_name": "14 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896184", "drug_name": "60 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896185", "drug_name": "60 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896186", "drug_name": "14 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896190", "drug_name": "14 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896209", "drug_name": "60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896212", "drug_name": "60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896218", "drug_name": "14 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896222", "drug_name": "14 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896228", "drug_name": "60 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896229", "drug_name": "60 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896235", "drug_name": "60 ACTUAT Fluticasone propionate 0.045 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896237", "drug_name": "120 ACTUAT Fluticasone propionate 0.045 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896243", "drug_name": "60 ACTUAT Fluticasone propionate 0.115 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896245", "drug_name": "120 ACTUAT Fluticasone propionate 0.115 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896271", "drug_name": "60 ACTUAT Fluticasone propionate 0.23 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896273", "drug_name": "120 ACTUAT Fluticasone propionate 0.23 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler [Advair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "896321", "drug_name": "120 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896323", "drug_name": "120 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler [Flonase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896324", "drug_name": "60 ACTUAT Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896758", "drug_name": "Labetalol hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896762", "drug_name": "Labetalol hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896766", "drug_name": "Labetalol hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896790", "drug_name": "Ribasphere RibaPak 1000 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896856", "drug_name": "Chorionic Gonadotropin 10000 UNT/ML Injectable Solution [Pregnyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "896872", "drug_name": "Chorionic Gonadotropin 10000 UNT/ML Injectable Solution [Novarel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897021", "drug_name": "12 HR dalfampridine 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897025", "drug_name": "12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897044", "drug_name": "Somatropin 8.8 MG Cartridge [Saizen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897126", "drug_name": "3 ML liraglutide 6 MG/ML Pen Injector [Victoza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897139", "drug_name": "Potassium Chloride 0.167 MEQ/ML Oral Solution [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897256", "drug_name": "Ferrous fumarate 324 MG Oral Tablet [Hemocyte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897294", "drug_name": "Nedocromil Sodium 20 MG/ML Ophthalmic Solution [Alocril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897584", "drug_name": "24 HR Verapamil hydrochloride 100 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897586", "drug_name": "24 HR Verapamil hydrochloride 100 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897590", "drug_name": "24 HR Verapamil hydrochloride 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897592", "drug_name": "24 HR Verapamil hydrochloride 200 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897596", "drug_name": "24 HR Verapamil hydrochloride 300 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897598", "drug_name": "24 HR Verapamil hydrochloride 300 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897612", "drug_name": "24 HR Verapamil hydrochloride 120 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897614", "drug_name": "24 HR Verapamil hydrochloride 120 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897618", "drug_name": "24 HR Verapamil hydrochloride 180 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897620", "drug_name": "24 HR Verapamil hydrochloride 180 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897624", "drug_name": "24 HR Verapamil hydrochloride 240 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897626", "drug_name": "24 HR Verapamil hydrochloride 240 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897630", "drug_name": "24 HR Verapamil hydrochloride 360 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897632", "drug_name": "24 HR Verapamil hydrochloride 360 MG Extended Release Oral Capsule [Verelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897640", "drug_name": "Verapamil hydrochloride 180 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897649", "drug_name": "Verapamil hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897657", "drug_name": "Hydromorphone Hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897658", "drug_name": "Hydromorphone Hydrochloride 1 MG/ML Oral Solution [Dilaudid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897659", "drug_name": "Verapamil hydrochloride 120 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897661", "drug_name": "Verapamil hydrochloride 120 MG Extended Release Oral Tablet [Calan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897666", "drug_name": "Verapamil hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897667", "drug_name": "Verapamil hydrochloride 120 MG Oral Tablet [Calan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897676", "drug_name": "Verapamil hydrochloride 180 MG Extended Release Oral Tablet [Calan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897680", "drug_name": "Verapamil hydrochloride 240 MG Extended Release Oral Tablet [Calan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897683", "drug_name": "Verapamil hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897685", "drug_name": "Verapamil hydrochloride 80 MG Oral Tablet [Calan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897696", "drug_name": "Hydromorphone Hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897698", "drug_name": "Hydromorphone Hydrochloride 2 MG Oral Tablet [Dilaudid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897702", "drug_name": "Hydromorphone Hydrochloride 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897704", "drug_name": "Hydromorphone Hydrochloride 4 MG Oral Tablet [Dilaudid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897710", "drug_name": "Hydromorphone Hydrochloride 8 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897712", "drug_name": "Hydromorphone Hydrochloride 8 MG Oral Tablet [Dilaudid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897722", "drug_name": "Verapamil hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897749", "drug_name": "Hydromorphone Hydrochloride 3 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "897756", "drug_name": "1 ML Hydromorphone Hydrochloride 1 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897781", "drug_name": "24 HR trandolapril 1 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897782", "drug_name": "24 HR trandolapril 1 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet [Tarka]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897783", "drug_name": "24 HR trandolapril 2 MG / Verapamil hydrochloride 180 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897785", "drug_name": "24 HR trandolapril 2 MG / Verapamil hydrochloride 180 MG Extended Release Oral Tablet [Tarka]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897844", "drug_name": "24 HR trandolapril 2 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897846", "drug_name": "24 HR trandolapril 2 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet [Tarka]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897853", "drug_name": "24 HR trandolapril 4 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "897855", "drug_name": "24 HR trandolapril 4 MG / Verapamil hydrochloride 240 MG Extended Release Oral Tablet [Tarka]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898342", "drug_name": "Amlodipine 10 MG / Benazepril hydrochloride 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898344", "drug_name": "Amlodipine 10 MG / Benazepril hydrochloride 20 MG Oral Capsule [Lotrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898348", "drug_name": "Amlodipine 10 MG / Benazepril hydrochloride 40 MG Oral Capsule [Lotrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898350", "drug_name": "Amlodipine 2.5 MG / Benazepril hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898353", "drug_name": "Amlodipine 5 MG / Benazepril hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898355", "drug_name": "Amlodipine 5 MG / Benazepril hydrochloride 10 MG Oral Capsule [Lotrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898356", "drug_name": "Amlodipine 5 MG / Benazepril hydrochloride 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898358", "drug_name": "Amlodipine 5 MG / Benazepril hydrochloride 20 MG Oral Capsule [Lotrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898361", "drug_name": "Amlodipine 5 MG / Benazepril hydrochloride 40 MG Oral Capsule [Lotrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898362", "drug_name": "Benazepril hydrochloride 10 MG / Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898366", "drug_name": "Benazepril hydrochloride 10 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Lotensin HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898367", "drug_name": "Benazepril hydrochloride 20 MG / Hydrochlorothiazide 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898371", "drug_name": "Benazepril hydrochloride 20 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Lotensin HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898372", "drug_name": "Benazepril hydrochloride 20 MG / Hydrochlorothiazide 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898376", "drug_name": "Benazepril hydrochloride 20 MG / Hydrochlorothiazide 25 MG Oral Tablet [Lotensin HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898378", "drug_name": "Benazepril hydrochloride 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898418", "drug_name": "Flurandrenolide 0.25 MG/ML Topical Cream [Cordran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "898420", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Cream [Cordran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "898490", "drug_name": "potassium citrate 15 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898517", "drug_name": "potassium citrate 15 MEQ Extended Release Oral Tablet [Urocit-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898591", "drug_name": "Octreotide 20 MG Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898603", "drug_name": "Octreotide 30 MG Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898607", "drug_name": "Octreotide 10 MG Injection [Sandostatin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898687", "drug_name": "Benazepril hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898689", "drug_name": "Benazepril hydrochloride 10 MG Oral Tablet [Lotensin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898690", "drug_name": "Benazepril hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898692", "drug_name": "Benazepril hydrochloride 20 MG Oral Tablet [Lotensin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898715", "drug_name": "pregabalin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898718", "drug_name": "pregabalin 20 MG/ML Oral Solution [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898719", "drug_name": "Benazepril hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898721", "drug_name": "Benazepril hydrochloride 40 MG Oral Tablet [Lotensin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "898723", "drug_name": "Benazepril hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899122", "drug_name": "24 HR Ciprofloxacin 500 MG Extended Release Oral Tablet [Cipro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899439", "drug_name": "24 HR dexmethylphenidate hydrochloride 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899441", "drug_name": "24 HR dexmethylphenidate hydrochloride 10 MG Extended Release Oral Capsule [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899461", "drug_name": "24 HR dexmethylphenidate hydrochloride 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899463", "drug_name": "24 HR dexmethylphenidate hydrochloride 15 MG Extended Release Oral Capsule [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899485", "drug_name": "24 HR dexmethylphenidate hydrochloride 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899487", "drug_name": "24 HR dexmethylphenidate hydrochloride 20 MG Extended Release Oral Capsule [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899495", "drug_name": "24 HR dexmethylphenidate hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899497", "drug_name": "24 HR dexmethylphenidate hydrochloride 30 MG Extended Release Oral Capsule [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899511", "drug_name": "24 HR dexmethylphenidate hydrochloride 5 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899513", "drug_name": "24 HR dexmethylphenidate hydrochloride 5 MG Extended Release Oral Capsule [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899518", "drug_name": "dexmethylphenidate hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899519", "drug_name": "dexmethylphenidate hydrochloride 5 MG Oral Tablet [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899521", "drug_name": "24 HR Nitroglycerin 0.2 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899548", "drug_name": "dexmethylphenidate hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899549", "drug_name": "dexmethylphenidate hydrochloride 10 MG Oral Tablet [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899557", "drug_name": "dexmethylphenidate hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899559", "drug_name": "dexmethylphenidate hydrochloride 2.5 MG Oral Tablet [Focalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "899607", "drug_name": "24 HR Nitroglycerin 0.4 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899642", "drug_name": "24 HR Nitroglycerin 0.6 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899660", "drug_name": "24 HR Nitroglycerin 0.1 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899690", "drug_name": "24 HR Nitroglycerin 0.3 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "899705", "drug_name": "24 HR Nitroglycerin 0.8 MG/HR Transdermal System [Nitro-Dur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900038", "drug_name": "Phentermine Hydrochloride 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900145", "drug_name": "24 HR lamotrigine 100 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900157", "drug_name": "24 HR lamotrigine 200 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900165", "drug_name": "24 HR lamotrigine 25 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900169", "drug_name": "24 HR lamotrigine 50 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900575", "drug_name": "Ritonavir 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "900577", "drug_name": "Ritonavir 100 MG Oral Tablet [Norvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "900866", "drug_name": "Lamictal XR Green Patient Titration Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900891", "drug_name": "Lamictal XR Orange Patient Titration Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "900984", "drug_name": "Lamictal XR Blue Patient Titration Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901280", "drug_name": "Sodium Fluoride 0.55 MG Chewable Tablet [Ludent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901288", "drug_name": "Sodium Fluoride 1.1 MG Chewable Tablet [Ludent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901401", "drug_name": "doxycycline anhydrous 40 MG Delayed Release Oral Capsule [Oracea]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901537", "drug_name": "24 HR Pramipexole dihydrochloride 4.5 MG Extended Release Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901543", "drug_name": "24 HR Pramipexole dihydrochloride 0.375 MG Extended Release Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901547", "drug_name": "24 HR Pramipexole dihydrochloride 0.75 MG Extended Release Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901551", "drug_name": "24 HR Pramipexole dihydrochloride 1.5 MG Extended Release Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901557", "drug_name": "24 HR Pramipexole dihydrochloride 3 MG Extended Release Oral Tablet [Mirapex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "901614", "drug_name": "Aztreonam 75 MG/ML Inhalation Solution [Cayston]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "901644", "drug_name": "0.5 ML Streptococcus pneumoniae serotype 1 capsular antigen diphtheria CRM197 protein conjugate vaccine 0.0044 MG/ML / Streptococcus pneumoniae serotype 14 capsular antigen diphtheria CRM197 protein conjugate vaccine 0.0044 MG/ML / Streptococcus pneumoniae serotype 18C capsular antigen diphtheria CRM197 protein conjugate vaccine 0.0044 MG/ML / Streptococcus pneumoniae serotype 19A capsular antigen diphtheria CRM197 protein conjugate vaccine 0.0044 MG/ML / Streptococcus pneumoniae serot", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "901802", "drug_name": "zolmitriptan 2.5 MG Disintegrating Oral Tablet [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "901803", "drug_name": "zolmitriptan 5 MG Disintegrating Oral Tablet [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "901812", "drug_name": "velaglucerase alfa 400 UNT Injection [Vpriv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "902312", "drug_name": "Ribasphere RibaPak 800 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "902313", "drug_name": "Ribasphere RibaPak 1200 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "902624", "drug_name": "dexlansoprazole 30 MG Delayed Release Oral Capsule [Dexilant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902626", "drug_name": "dexlansoprazole 60 MG Delayed Release Oral Capsule [Dexilant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902648", "drug_name": "12 HR Disopyramide 100 MG Extended Release Oral Capsule [Norpace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "902652", "drug_name": "12 HR Disopyramide 150 MG Extended Release Oral Capsule [Norpace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "902729", "drug_name": "24 HR Hydromorphone Hydrochloride 12 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902733", "drug_name": "24 HR Hydromorphone Hydrochloride 12 MG Extended Release Oral Tablet [Exalgo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902736", "drug_name": "24 HR Hydromorphone Hydrochloride 16 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902738", "drug_name": "24 HR Hydromorphone Hydrochloride 16 MG Extended Release Oral Tablet [Exalgo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902741", "drug_name": "24 HR Hydromorphone Hydrochloride 8 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "902743", "drug_name": "24 HR Hydromorphone Hydrochloride 8 MG Extended Release Oral Tablet [Exalgo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "903287", "drug_name": "Levothyroxine Sodium 0.0125 MG / liothyronine sodium 0.0031 MG Oral Tablet [Thyrolar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903302", "drug_name": "Levothyroxine Sodium 0.15 MG / liothyronine sodium 0.0375 MG Oral Tablet [Thyrolar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903309", "drug_name": "Levothyroxine Sodium 0.1 MG / liothyronine sodium 0.025 MG Oral Tablet [Thyrolar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903316", "drug_name": "Levothyroxine Sodium 0.025 MG / liothyronine sodium 0.00625 MG Oral Tablet [Thyrolar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903442", "drug_name": "Levothyroxine Sodium 0.05 MG / liothyronine sodium 0.0125 MG Oral Tablet [Thyrolar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903456", "drug_name": "liothyronine sodium 0.005 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903458", "drug_name": "liothyronine sodium 0.005 MG Oral Tablet [Cytomel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903697", "drug_name": "liothyronine sodium 0.025 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903699", "drug_name": "liothyronine sodium 0.025 MG Oral Tablet [Cytomel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903703", "drug_name": "liothyronine sodium 0.05 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903705", "drug_name": "liothyronine sodium 0.05 MG Oral Tablet [Cytomel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903843", "drug_name": "Pyridostigmine Bromide 12 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903845", "drug_name": "Pyridostigmine Bromide 12 MG/ML Oral Solution [Mestinon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903849", "drug_name": "Pyridostigmine Bromide 180 MG Extended Release Oral Tablet [Mestinon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903857", "drug_name": "Pyridostigmine Bromide 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903859", "drug_name": "Pyridostigmine Bromide 60 MG Oral Tablet [Mestinon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903884", "drug_name": "Fluvoxamine Maleate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903887", "drug_name": "Fluvoxamine Maleate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "903891", "drug_name": "Fluvoxamine Maleate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904158", "drug_name": "POLYETHYLENE GLYCOL 3350 420000 MG / Potassium Chloride 1480 MG / Sodium Bicarbonate 5720 MG / Sodium Chloride 11200 MG Powder for Oral Solution [TriLyte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904170", "drug_name": "Primaquine Phosphate 26.3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904368", "drug_name": "Benzphetamine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904396", "drug_name": "Alendronic acid 35 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904405", "drug_name": "Alendronic acid 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904415", "drug_name": "Nalbuphine Hydrochloride 10 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904419", "drug_name": "Alendronic acid 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904425", "drug_name": "Alendronic acid 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904431", "drug_name": "Alendronic acid 70 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904433", "drug_name": "Alendronic acid 70 MG Oral Tablet [Fosamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904440", "drug_name": "Nalbuphine Hydrochloride 20 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904458", "drug_name": "Pravastatin Sodium 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904465", "drug_name": "Alendronic acid 70 MG / Cholecalciferol 5600 UNT Oral Tablet [Fosamax Plus D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904467", "drug_name": "Pravastatin Sodium 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904469", "drug_name": "Pravastatin Sodium 20 MG Oral Tablet [Pravachol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904475", "drug_name": "Pravastatin Sodium 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904477", "drug_name": "Pravastatin Sodium 40 MG Oral Tablet [Pravachol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904481", "drug_name": "Pravastatin Sodium 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904483", "drug_name": "Pravastatin Sodium 80 MG Oral Tablet [Pravachol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904495", "drug_name": "Alendronic acid 70 MG / Cholecalciferol 2800 UNT Oral Tablet [Fosamax Plus D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904535", "drug_name": "Etidronate Disodium 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904547", "drug_name": "Etidronate Disodium 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904567", "drug_name": "Sotalol Hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904569", "drug_name": "Sotalol Hydrochloride 120 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904571", "drug_name": "Sotalol Hydrochloride 120 MG Oral Tablet [Sorine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904579", "drug_name": "Sotalol Hydrochloride 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904581", "drug_name": "Sotalol Hydrochloride 160 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904583", "drug_name": "Sotalol Hydrochloride 160 MG Oral Tablet [Sorine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904589", "drug_name": "Sotalol Hydrochloride 240 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904591", "drug_name": "Sotalol Hydrochloride 240 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904593", "drug_name": "Sotalol Hydrochloride 240 MG Oral Tablet [Sorine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904601", "drug_name": "Sotalol Hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904603", "drug_name": "Sotalol Hydrochloride 80 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904605", "drug_name": "Sotalol Hydrochloride 80 MG Oral Tablet [Sorine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904783", "drug_name": "hydrocortisone acetate 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Foam [Epifoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "904870", "drug_name": "168 HR Buprenorphine 0.01 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904874", "drug_name": "168 HR Buprenorphine 0.01 MG/HR Transdermal System [BuTrans]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904876", "drug_name": "168 HR Buprenorphine 0.02 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904878", "drug_name": "168 HR Buprenorphine 0.02 MG/HR Transdermal System [BuTrans]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904880", "drug_name": "168 HR Buprenorphine 0.005 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904882", "drug_name": "168 HR Buprenorphine 0.005 MG/HR Transdermal System [BuTrans]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904932", "drug_name": "ibandronic acid 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904934", "drug_name": "ibandronic acid 150 MG Oral Tablet [Boniva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "904954", "drug_name": "3 ML ibandronic acid 1 MG/ML Prefilled Syringe [Boniva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905024", "drug_name": "risedronate sodium 35 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905026", "drug_name": "risedronate sodium 35 MG Oral Tablet [Actonel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905028", "drug_name": "risedronate sodium 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905030", "drug_name": "risedronate sodium 150 MG Oral Tablet [Actonel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905032", "drug_name": "risedronate sodium 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905034", "drug_name": "risedronate sodium 30 MG Oral Tablet [Actonel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905041", "drug_name": "risedronate sodium 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905043", "drug_name": "risedronate sodium 5 MG Oral Tablet [Actonel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905057", "drug_name": "Triptorelin 22.5 MG Injection [Trelstar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905059", "drug_name": "Triptorelin 3.75 MG Injection [Trelstar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905064", "drug_name": "Triptorelin 11.25 MG Injection [Trelstar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905092", "drug_name": "{4 (risedronate sodium 35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905093", "drug_name": "Actonel 35 4-Week Once Weekly Dosepack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905100", "drug_name": "{12 (risedronate sodium 35 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905101", "drug_name": "Actonel 35 12-Week Once Weekly Dosepack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "905158", "drug_name": "Sirolimus 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905160", "drug_name": "Sirolimus 0.5 MG Oral Tablet [Rapamune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905164", "drug_name": "Olsalazine sodium 250 MG Oral Capsule [Dipentum]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905168", "drug_name": "Protriptyline Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905172", "drug_name": "Protriptyline Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905199", "drug_name": "Hydralazine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905222", "drug_name": "Hydralazine Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905225", "drug_name": "Hydralazine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905269", "drug_name": "Trihexyphenidyl Hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905273", "drug_name": "Trihexyphenidyl Hydrochloride 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905283", "drug_name": "Trihexyphenidyl Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905341", "drug_name": "Demeclocycline Hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905347", "drug_name": "Demeclocycline Hydrochloride 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905369", "drug_name": "Chlordiazepoxide Hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905379", "drug_name": "Hydralazine Hydrochloride 37.5 MG / Isosorbide Dinitrate 20 MG Oral Tablet [Bidil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905385", "drug_name": "adapalene 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905387", "drug_name": "adapalene 1 MG/ML Topical Lotion [Differin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905394", "drug_name": "Carglumic acid 200 MG Tablet for Oral Suspension [Carbaglu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905395", "drug_name": "Hydralazine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905453", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905457", "drug_name": "Levothyroxine Sodium 0.137 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905460", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905464", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905495", "drug_name": "Chlordiazepoxide Hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "905516", "drug_name": "Chlordiazepoxide Hydrochloride 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966153", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966157", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966158", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966160", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966164", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966166", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966170", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966171", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966173", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966175", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966177", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966182", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966184", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966185", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966187", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966190", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966191", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966194", "drug_name": "Levothyroxine Sodium 0.137 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966196", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966200", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966201", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966202", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966204", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966205", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966207", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966211", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966218", "drug_name": "Levothyroxine Sodium 0.3 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966220", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966221", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966222", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966224", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966225", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966228", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966232", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966233", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966235", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966237", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966238", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966241", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966243", "drug_name": "Levothyroxine Sodium 0.3 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966244", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966246", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966247", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966248", "drug_name": "Levothyroxine Sodium 0.112 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966249", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966250", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966251", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966253", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966270", "drug_name": "Levothyroxine Sodium 0.137 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966271", "drug_name": "Levothyroxine Sodium 0.137 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966282", "drug_name": "Levothyroxine Sodium 0.088 MG Oral Tablet [Synthroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966283", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Tablet [Levoxyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966286", "drug_name": "Levothyroxine Sodium 0.075 MG Oral Tablet [Unithroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966415", "drug_name": "Levothyroxine Sodium 0.1 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966417", "drug_name": "Levothyroxine Sodium 0.125 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966420", "drug_name": "Levothyroxine Sodium 0.15 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966423", "drug_name": "Levothyroxine Sodium 0.025 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966426", "drug_name": "Levothyroxine Sodium 0.05 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966434", "drug_name": "Levothyroxine Sodium 0.013 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966524", "drug_name": "120 ACTUAT Budesonide 0.18 MG/ACTUAT Dry Powder Inhaler [Pulmicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966529", "drug_name": "60 ACTUAT Budesonide 0.09 MG/ACTUAT Dry Powder Inhaler [Pulmicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966538", "drug_name": "100 ACTUAT Beclomethasone Dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler [Qvar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966547", "drug_name": "180 ACTUAT Beclomethasone Dipropionate 0.042 MG/ACTUAT Nasal Inhaler [Beconase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966577", "drug_name": "diflorasone diacetate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966589", "drug_name": "diflorasone diacetate 0.5 MG/ML Topical Cream [Psorcon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966607", "drug_name": "diflorasone diacetate 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966787", "drug_name": "Doxepin 3 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966791", "drug_name": "Doxepin 3 MG Oral Tablet [Silenor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966793", "drug_name": "Doxepin 6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966795", "drug_name": "Doxepin 6 MG Oral Tablet [Silenor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966820", "drug_name": "diflorasone diacetate 0.5 MG/ML Topical Cream [Apexicon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "966914", "drug_name": "POLYETHYLENE GLYCOL 3350 240000 MG / Potassium Chloride 2980 MG / Sodium Bicarbonate 6720 MG / Sodium Chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966916", "drug_name": "POLYETHYLENE GLYCOL 3350 227100 MG / Potassium Chloride 2820 MG / Sodium Bicarbonate 6360 MG / Sodium Chloride 5530 MG / sodium sulfate 21500 MG Powder for Oral Solution [Golytely]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966920", "drug_name": "POLYETHYLENE GLYCOL 3350 236000 MG / Potassium Chloride 2970 MG / Sodium Bicarbonate 6740 MG / Sodium Chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "966922", "drug_name": "POLYETHYLENE GLYCOL 3350 236000 MG / Potassium Chloride 2970 MG / Sodium Bicarbonate 6740 MG / Sodium Chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Golytely]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "967014", "drug_name": "POLYETHYLENE GLYCOL 3350 240000 MG / Potassium Chloride 2980 MG / Sodium Bicarbonate 6720 MG / Sodium Chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [Colyte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "967017", "drug_name": "imiquimod 37.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "967021", "drug_name": "imiquimod 37.5 MG/ML Topical Cream [Zyclara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "968766", "drug_name": "Phentermine Hydrochloride 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "968849", "drug_name": "Nicotine 2 MG Oral Lozenge [Nicorette]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "968851", "drug_name": "Nicotine 4 MG Oral Lozenge [Nicorette]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977427", "drug_name": "everolimus 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977431", "drug_name": "everolimus 0.25 MG Oral Tablet [Zortress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977434", "drug_name": "everolimus 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977436", "drug_name": "everolimus 0.5 MG Oral Tablet [Zortress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977438", "drug_name": "everolimus 0.75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977440", "drug_name": "everolimus 0.75 MG Oral Tablet [Zortress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977840", "drug_name": "3 ML insulin aspart protamine, human 70 UNT/ML / insulin aspart, human 30 UNT/ML Pen Injector [NovoLog Mix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977842", "drug_name": "insulin aspart protamine, human 70 UNT/ML / insulin aspart, human 30 UNT/ML Injectable Suspension [NovoLog Mix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977860", "drug_name": "Methamphetamine Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977861", "drug_name": "Methamphetamine Hydrochloride 5 MG Oral Tablet [Desoxyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977874", "drug_name": "12 HR Oxymorphone Hydrochloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977876", "drug_name": "12 HR Oxymorphone Hydrochloride 10 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977880", "drug_name": "Amiloride Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977883", "drug_name": "Amiloride Hydrochloride 5 MG / Hydrochlorothiazide 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977894", "drug_name": "12 HR Oxymorphone Hydrochloride 15 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977896", "drug_name": "12 HR Oxymorphone Hydrochloride 15 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977902", "drug_name": "12 HR Oxymorphone Hydrochloride 20 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977904", "drug_name": "12 HR Oxymorphone Hydrochloride 20 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977909", "drug_name": "12 HR Oxymorphone Hydrochloride 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977911", "drug_name": "12 HR Oxymorphone Hydrochloride 30 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977915", "drug_name": "12 HR Oxymorphone Hydrochloride 40 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977917", "drug_name": "12 HR Oxymorphone Hydrochloride 40 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977923", "drug_name": "12 HR Oxymorphone Hydrochloride 5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977925", "drug_name": "12 HR Oxymorphone Hydrochloride 5 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977929", "drug_name": "12 HR Oxymorphone Hydrochloride 7.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977931", "drug_name": "12 HR Oxymorphone Hydrochloride 7.5 MG Extended Release Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977939", "drug_name": "Oxymorphone Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977940", "drug_name": "Oxymorphone Hydrochloride 5 MG Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977942", "drug_name": "Oxymorphone Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977943", "drug_name": "Oxymorphone Hydrochloride 10 MG Oral Tablet [Opana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "977978", "drug_name": "halobetasol propionate 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977980", "drug_name": "halobetasol propionate 0.0005 MG/MG Topical Ointment [Ultravate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977990", "drug_name": "halobetasol propionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "977992", "drug_name": "halobetasol propionate 0.5 MG/ML Topical Cream [Ultravate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978006", "drug_name": "Loperamide Hydrochloride 2 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "978573", "drug_name": "Carteolol Hydrochloride 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978654", "drug_name": "Diethylpropion Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978668", "drug_name": "24 HR Diethylpropion Hydrochloride 75 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978727", "drug_name": "0.2 ML Dalteparin Sodium 12500 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978735", "drug_name": "0.2 ML Dalteparin Sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978737", "drug_name": "0.3 ML Dalteparin Sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978741", "drug_name": "0.5 ML Dalteparin Sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978745", "drug_name": "0.6 ML Dalteparin Sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978747", "drug_name": "0.72 ML Dalteparin Sodium 25000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978757", "drug_name": "1 ML Dalteparin Sodium 10000 UNT/ML Prefilled Syringe [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978778", "drug_name": "Dalteparin Sodium 25000 UNT/ML Injectable Solution [Fragmin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "978950", "drug_name": "Natazia 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979092", "drug_name": "Hydroxychloroquine Sulfate 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979094", "drug_name": "Hydroxychloroquine Sulfate 200 MG Oral Tablet [Plaquenil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979338", "drug_name": "folic acid 1 MG / polysaccharide iron complex 150 MG / vitamin B12 0.025 MG Oral Capsule [Poly Iron 150 Forte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979409", "drug_name": "Metaproterenol Sulfate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979444", "drug_name": "Metaproterenol Sulfate 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979464", "drug_name": "Hydrochlorothiazide 12.5 MG / Losartan Potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979466", "drug_name": "Hydrochlorothiazide 12.5 MG / Losartan Potassium 100 MG Oral Tablet [Hyzaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979468", "drug_name": "Hydrochlorothiazide 12.5 MG / Losartan Potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979470", "drug_name": "Hydrochlorothiazide 12.5 MG / Losartan Potassium 50 MG Oral Tablet [Hyzaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979471", "drug_name": "Hydrochlorothiazide 25 MG / Losartan Potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979473", "drug_name": "Hydrochlorothiazide 25 MG / Losartan Potassium 100 MG Oral Tablet [Hyzaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979475", "drug_name": "Metaproterenol Sulfate 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979480", "drug_name": "Losartan Potassium 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979482", "drug_name": "Losartan Potassium 100 MG Oral Tablet [Cozaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979485", "drug_name": "Losartan Potassium 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979487", "drug_name": "Losartan Potassium 25 MG Oral Tablet [Cozaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979492", "drug_name": "Losartan Potassium 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979494", "drug_name": "Losartan Potassium 50 MG Oral Tablet [Cozaar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "979543", "drug_name": "24 HR phendimetrazine tartrate 105 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "979549", "drug_name": "phendimetrazine tartrate 35 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "984105", "drug_name": "Sodium phenylbutyrate 0.94 MG/MG Oral Powder", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991039", "drug_name": "Chlorpromazine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991044", "drug_name": "Chlorpromazine hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991061", "drug_name": "Dicyclomine Hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991063", "drug_name": "Dicyclomine Hydrochloride 10 MG Oral Capsule [Bentyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991086", "drug_name": "Dicyclomine Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991088", "drug_name": "Dicyclomine Hydrochloride 20 MG Oral Tablet [Bentyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991147", "drug_name": "Methadone Hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "991149", "drug_name": "Methadone Hydrochloride 10 MG/ML Oral Solution [Methadose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "991188", "drug_name": "Chlorpromazine hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991194", "drug_name": "Chlorpromazine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991336", "drug_name": "Chlorpromazine hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991486", "drug_name": "Codeine Phosphate 2 MG/ML / Promethazine Hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "991528", "drug_name": "Dextromethorphan Hydrobromide 3 MG/ML / Promethazine Hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992150", "drug_name": "methenamine hippurate 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992152", "drug_name": "methenamine hippurate 1000 MG Oral Tablet [Hiprex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992153", "drug_name": "methenamine mandelate 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992184", "drug_name": "methenamine mandelate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992399", "drug_name": "gatifloxacin 5 MG/ML Ophthalmic Solution [Zymaxid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992403", "drug_name": "2 ML Somatropin 2.5 MG/ML Pen Injector [Nutropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992420", "drug_name": "8 ACTUAT Ketorolac Tromethamine 15.8 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "992424", "drug_name": "8 ACTUAT Ketorolac Tromethamine 15.8 MG/ACTUAT Nasal Inhaler [Sprix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "992432", "drug_name": "Promethazine Hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "992438", "drug_name": "Promethazine Hydrochloride 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992441", "drug_name": "Promethazine Hydrochloride 12.5 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992445", "drug_name": "Promethazine Hydrochloride 12.5 MG Rectal Suppository [Promethegan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992447", "drug_name": "Promethazine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992454", "drug_name": "Promethazine Hydrochloride 25 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992459", "drug_name": "Promethazine Hydrochloride 25 MG Rectal Suppository [Promethegan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992475", "drug_name": "Promethazine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992481", "drug_name": "Promethazine Hydrochloride 50 MG Rectal Suppository [Promethegan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992656", "drug_name": "homatropine methylbromide 1.5 MG / Hydrocodone Bitartrate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992668", "drug_name": "homatropine methylbromide 0.3 MG/ML / Hydrocodone Bitartrate 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992675", "drug_name": "homatropine methylbromide 0.3 MG/ML / Hydrocodone Bitartrate 1 MG/ML Oral Solution [Hydromet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992733", "drug_name": "homatropine methylbromide 1.5 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Tussigon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992757", "drug_name": "Homatropine hydrobromide 50 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "992759", "drug_name": "Homatropine hydrobromide 50 MG/ML Ophthalmic Solution [Homatropaire]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993456", "drug_name": "1 ML denosumab 60 MG/ML Prefilled Syringe [Prolia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993462", "drug_name": "midodrine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993466", "drug_name": "midodrine hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993470", "drug_name": "midodrine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993503", "drug_name": "12 HR Bupropion Hydrochloride 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993511", "drug_name": "12 HR Bupropion Hydrochloride 100 MG Extended Release Oral Tablet [Wellbutrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993518", "drug_name": "12 HR Bupropion Hydrochloride 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993528", "drug_name": "12 HR Bupropion Hydrochloride 150 MG Extended Release Oral Tablet [Wellbutrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993536", "drug_name": "12 HR Bupropion Hydrochloride 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993537", "drug_name": "12 HR Bupropion Hydrochloride 200 MG Extended Release Oral Tablet [Wellbutrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993541", "drug_name": "24 HR Bupropion Hydrochloride 150 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993545", "drug_name": "24 HR Bupropion Hydrochloride 150 MG Extended Release Oral Tablet [Wellbutrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993552", "drug_name": "24 HR Bupropion hydrobromide 174 MG Extended Release Oral Tablet [Aplenzin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993557", "drug_name": "24 HR Bupropion Hydrochloride 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993564", "drug_name": "24 HR Bupropion Hydrochloride 300 MG Extended Release Oral Tablet [Wellbutrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993569", "drug_name": "24 HR Bupropion hydrobromide 348 MG Extended Release Oral Tablet [Aplenzin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993683", "drug_name": "24 HR Bupropion hydrobromide 522 MG Extended Release Oral Tablet [Aplenzin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993687", "drug_name": "Bupropion Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993691", "drug_name": "Bupropion Hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993755", "drug_name": "Acetaminophen 24 MG/ML / Codeine Phosphate 2.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993767", "drug_name": "Acetaminophen 24 MG/ML / Codeine Phosphate 2.4 MG/ML Oral Suspension [Capital and Codeine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993770", "drug_name": "Acetaminophen 300 MG / Codeine Phosphate 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993781", "drug_name": "Acetaminophen 300 MG / Codeine Phosphate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993804", "drug_name": "Gianvi 28-Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "993837", "drug_name": "Acetaminophen 300 MG / Codeine Phosphate 30 MG Oral Tablet [Tylenol with Codeine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993890", "drug_name": "Acetaminophen 300 MG / Codeine Phosphate 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993892", "drug_name": "Acetaminophen 300 MG / Codeine Phosphate 60 MG Oral Tablet [Tylenol with Codeine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993943", "drug_name": "Acetaminophen 325 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "993954", "drug_name": "Smoking Cessation 12 HR Bupropion Hydrochloride 150 MG Extended Release Oral Tablet [Zyban]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994005", "drug_name": "Esomeprazole 20 MG / Naproxen 375 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994007", "drug_name": "Esomeprazole 20 MG / Naproxen 375 MG Delayed Release Oral Tablet [Vimovo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994008", "drug_name": "Esomeprazole 20 MG / Naproxen 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994010", "drug_name": "Esomeprazole 20 MG / Naproxen 500 MG Delayed Release Oral Tablet [Vimovo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994226", "drug_name": "Aspirin 325 MG / Carisoprodol 200 MG / Codeine Phosphate 16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "994237", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "994239", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule [Ascomp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "994277", "drug_name": "Aspirin 325 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule [Fiorinal with Codeine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "994404", "drug_name": "Brompheniramine Maleate 0.4 MG/ML / Codeine Phosphate 1.5 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Mar-cof BP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994521", "drug_name": "12 HR Orphenadrine Citrate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "994537", "drug_name": "Aspirin 770 MG / Caffeine 60 MG / Orphenadrine Citrate 50 MG Oral Tablet [Norgesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "994539", "drug_name": "Aspirin 770 MG / Caffeine 60 MG / Orphenadrine Citrate 50 MG Oral Tablet [Orphengesic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "995019", "drug_name": "Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray [Nitrolingual]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995043", "drug_name": "Chlorpheniramine Maleate 0.2 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 3 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995064", "drug_name": "Chlorpheniramine Maleate 0.2 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995067", "drug_name": "Chlorpheniramine Maleate 0.222 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 3.33 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995070", "drug_name": "Chlorpheniramine Maleate 0.222 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995073", "drug_name": "Chlorpheniramine Maleate 0.25 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995077", "drug_name": "Chlorpheniramine Maleate 0.25 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 0.375 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995081", "drug_name": "Chlorpheniramine Maleate 0.266 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 4 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995084", "drug_name": "Chlorpheniramine Maleate 0.267 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995088", "drug_name": "Chlorpheniramine Maleate 0.286 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 4.29 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995095", "drug_name": "Chlorpheniramine Maleate 0.286 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995110", "drug_name": "Chlorpheniramine Maleate 0.333 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 5 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995118", "drug_name": "Chlorpheniramine Maleate 0.333 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995122", "drug_name": "Chlorpheniramine Maleate 0.4 MG/ML / Codeine Phosphate 1 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Suspension [Zodryl DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995125", "drug_name": "Chlorpheniramine Maleate 0.4 MG/ML / Codeine Phosphate 1 MG/ML Oral Suspension [Zodryl AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995132", "drug_name": "Chlorpheniramine Maleate 0.4 MG/ML / Codeine Phosphate 1.8 MG/ML Oral Solution [Z Tuss AC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995156", "drug_name": "lacosamide 10 MG/ML Oral Solution [Vimpat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995218", "drug_name": "Hydroxyzine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995232", "drug_name": "Hydroxyzine Pamoate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995241", "drug_name": "Hydroxyzine Hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995253", "drug_name": "Hydroxyzine Pamoate 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995255", "drug_name": "Hydroxyzine Pamoate 25 MG Oral Capsule [Vistaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995258", "drug_name": "Hydroxyzine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995278", "drug_name": "Hydroxyzine Pamoate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995280", "drug_name": "Hydroxyzine Pamoate 50 MG Oral Capsule [Vistaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995281", "drug_name": "Hydroxyzine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995440", "drug_name": "Codeine Phosphate 1.26 MG/ML / Guaifenesin 20 MG/ML Oral Solution [M-Clear WC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995443", "drug_name": "Codeine Phosphate 1.5 MG/ML / Guaifenesin 45 MG/ML Oral Solution [Mar-cof CG]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995599", "drug_name": "Ethambutol Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995607", "drug_name": "Ethambutol Hydrochloride 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995609", "drug_name": "Ethambutol Hydrochloride 400 MG Oral Tablet [Myambutol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995613", "drug_name": "ferrous sulfate 75 MG/ML Oral Solution [Fer-in-Sol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995624", "drug_name": "Meclizine Hydrochloride 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995666", "drug_name": "Meclizine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995868", "drug_name": "Codeine Phosphate 2 MG/ML / Guaifenesin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995872", "drug_name": "Codeine Phosphate 2 MG/ML / Guaifenesin 20 MG/ML Oral Solution [Cheratussin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "995993", "drug_name": "Codeine Phosphate 2 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Cheratussin DAC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996101", "drug_name": "Dutasteride 0.5 MG / Tamsulosin hydrochloride 0.4 MG Oral Capsule [Jalyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996183", "drug_name": "vardenafil 10 MG Disintegrating Oral Tablet [Staxyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "996263", "drug_name": "Codeine Phosphate 2 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Phenylhistine Expectorant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996520", "drug_name": "Dextromethorphan Hydrobromide 2 MG/ML / Guaifenesin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996559", "drug_name": "1 ML Somatropin 12 MG/ML Cartridge [Genotropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996561", "drug_name": "Memantine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996563", "drug_name": "Memantine hydrochloride 10 MG Oral Tablet [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996571", "drug_name": "Memantine hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996572", "drug_name": "{21 (Memantine hydrochloride 10 MG Oral Tablet) / 28 (Memantine hydrochloride 5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996574", "drug_name": "Memantine hydrochloride 5 MG Oral Tablet [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996597", "drug_name": "24 HR Memantine hydrochloride 14 MG Extended Release Oral Capsule [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996605", "drug_name": "24 HR Memantine hydrochloride 21 MG Extended Release Oral Capsule [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996611", "drug_name": "24 HR Memantine hydrochloride 28 MG Extended Release Oral Capsule [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996617", "drug_name": "24 HR Memantine hydrochloride 7 MG Extended Release Oral Capsule [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996633", "drug_name": "Namenda XR 28 Day Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996634", "drug_name": "Namenda 49 (5 MG / 10 MG) Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996740", "drug_name": "Memantine hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996742", "drug_name": "Memantine hydrochloride 2 MG/ML Oral Solution [Namenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996757", "drug_name": "Codeine Phosphate 2 MG/ML / Phenylephrine Hydrochloride 1 MG/ML / Promethazine Hydrochloride 1.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "996824", "drug_name": "Methylergonovine Maleate 0.2 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "996826", "drug_name": "Methylergonovine Maleate 0.2 MG Oral Tablet [Methergine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "996921", "drug_name": "Clozapine 200 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "996923", "drug_name": "Clozapine 200 MG Disintegrating Oral Tablet [Fazaclo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997006", "drug_name": "24 HR Lovastatin 20 MG Extended Release Oral Tablet [Altoprev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997007", "drug_name": "24 HR Lovastatin 40 MG Extended Release Oral Tablet [Altoprev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997012", "drug_name": "Quinine Sulfate 324 MG Oral Capsule [Qualaquin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997170", "drug_name": "Codeine sulfate 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997220", "drug_name": "Donepezil hydrochloride 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997223", "drug_name": "Donepezil hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997224", "drug_name": "Donepezil hydrochloride 10 MG Oral Tablet [Aricept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997226", "drug_name": "Donepezil hydrochloride 5 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997228", "drug_name": "Donepezil hydrochloride 5 MG Disintegrating Oral Tablet [Aricept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997229", "drug_name": "Donepezil hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997230", "drug_name": "Donepezil hydrochloride 5 MG Oral Tablet [Aricept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997287", "drug_name": "Codeine sulfate 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997296", "drug_name": "Codeine sulfate 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "997406", "drug_name": "12 HR Fexofenadine hydrochloride 60 MG / Pseudoephedrine Hydrochloride 120 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997420", "drug_name": "Fexofenadine hydrochloride 180 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997422", "drug_name": "Fexofenadine hydrochloride 180 MG Oral Tablet [Allegra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997484", "drug_name": "Fexofenadine hydrochloride 30 MG Disintegrating Oral Tablet [Allegra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997501", "drug_name": "Fexofenadine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997502", "drug_name": "Fexofenadine hydrochloride 60 MG Oral Tablet [Allegra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997512", "drug_name": "12 HR Fexofenadine hydrochloride 60 MG / Pseudoephedrine Hydrochloride 120 MG Extended Release Oral Tablet [Allegra-D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "997515", "drug_name": "24 HR Fexofenadine hydrochloride 180 MG / Pseudoephedrine Hydrochloride 240 MG Extended Release Oral Tablet [Allegra-D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998032", "drug_name": "Ondansetron 8 MG Oral Film [Zuplenz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998035", "drug_name": "Ondansetron 4 MG Oral Film [Zuplenz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998189", "drug_name": "everolimus 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "998191", "drug_name": "everolimus 2.5 MG Oral Tablet [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "998213", "drug_name": "1 ML Morphine Sulfate 4 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998426", "drug_name": "Acyclovir 50 MG/ML / Hydrocortisone 10 MG/ML Topical Cream [Xerese]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998541", "drug_name": "Miconazole Nitrate 20 MG/ML Vaginal Cream [Monistat]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998550", "drug_name": "Miconazole Nitrate 50 MG Buccal Tablet [Oravig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998671", "drug_name": "168 HR Clonidine 0.00417 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998673", "drug_name": "168 HR Clonidine 0.00417 MG/HR Transdermal System [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998675", "drug_name": "168 HR Clonidine 0.00833 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998677", "drug_name": "168 HR Clonidine 0.00833 MG/HR Transdermal System [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998679", "drug_name": "168 HR Clonidine 0.0125 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998681", "drug_name": "168 HR Clonidine 0.0125 MG/HR Transdermal System [Catapres]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998685", "drug_name": "Acebutolol 400 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998687", "drug_name": "Acebutolol 400 MG Oral Capsule [Sectral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998689", "drug_name": "Acebutolol 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "998691", "drug_name": "Acebutolol 200 MG Oral Capsule [Sectral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999613", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Medicated Liquid Soap", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999717", "drug_name": "potassium nitrate 0.05 MG/MG / Sodium Fluoride 0.011 MG/MG Toothpaste [Prevident 5000 Sensitive]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999913", "drug_name": "Benzoyl Peroxide 42.5 MG/ML Medicated Pad [Pacnex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999915", "drug_name": "Benzoyl Peroxide 70 MG/ML Medicated Pad [Pacnex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999965", "drug_name": "Glycopyrrolate 0.2 MG/ML Oral Solution [Cuvposa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999967", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999971", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 20 MG Oral Tablet [Tribenzor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999986", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999990", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet [Tribenzor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999991", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999995", "drug_name": "Amlodipine 10 MG / Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet [Tribenzor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "999996", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000000", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 12.5 MG / Olmesartan medoxomil 40 MG Oral Tablet [Tribenzor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000001", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000005", "drug_name": "Amlodipine 5 MG / Hydrochlorothiazide 25 MG / Olmesartan medoxomil 40 MG Oral Tablet [Tribenzor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000048", "drug_name": "Doxepin Hydrochloride 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000054", "drug_name": "Doxepin Hydrochloride 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000058", "drug_name": "Doxepin Hydrochloride 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000064", "drug_name": "Doxepin Hydrochloride 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000070", "drug_name": "Doxepin Hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000076", "drug_name": "Doxepin Hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000091", "drug_name": "Doxepin Hydrochloride 50 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000093", "drug_name": "Doxepin Hydrochloride 50 MG/ML Topical Cream [Prudoxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000095", "drug_name": "Doxepin Hydrochloride 50 MG/ML Topical Cream [Zonalon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000097", "drug_name": "Doxepin Hydrochloride 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000114", "drug_name": "medroxyprogesterone acetate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000124", "drug_name": "medroxyprogesterone acetate 10 MG Oral Tablet [Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000126", "drug_name": "1 ML medroxyprogesterone acetate 150 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000128", "drug_name": "1 ML medroxyprogesterone acetate 150 MG/ML Injection [Depo-Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000133", "drug_name": "medroxyprogesterone acetate 400 MG/ML Injectable Suspension [Depo-Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000135", "drug_name": "medroxyprogesterone acetate 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000139", "drug_name": "medroxyprogesterone acetate 2.5 MG Oral Tablet [Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000141", "drug_name": "medroxyprogesterone acetate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000145", "drug_name": "medroxyprogesterone acetate 5 MG Oral Tablet [Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000153", "drug_name": "1 ML medroxyprogesterone acetate 150 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000154", "drug_name": "1 ML medroxyprogesterone acetate 150 MG/ML Prefilled Syringe [Depo-Provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000158", "drug_name": "0.65 ML medroxyprogesterone acetate 160 MG/ML Prefilled Syringe [depo-subQ provera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000405", "drug_name": "norethindrone acetate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000407", "drug_name": "norethindrone acetate 5 MG Oral Tablet [Aygestin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000487", "drug_name": "Premphase 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000491", "drug_name": "Prempro 0.3/1.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000497", "drug_name": "Prempro 0.45/1.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000499", "drug_name": "Prempro 0.625/2.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000500", "drug_name": "Prempro 0.625/5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000647", "drug_name": "Pilocarpine Hydrochloride 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000656", "drug_name": "Pilocarpine Hydrochloride 10 MG/ML Ophthalmic Solution [Isoptocarpine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000736", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 20 MG/ML Topical Cream [Avar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000862", "drug_name": "Pilocarpine Hydrochloride 20 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000870", "drug_name": "Pilocarpine Hydrochloride 20 MG/ML Ophthalmic Solution [Isoptocarpine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000897", "drug_name": "Pilocarpine Hydrochloride 40 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000903", "drug_name": "Pilocarpine Hydrochloride 40 MG/ML Ophthalmic Solution [Isoptocarpine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000913", "drug_name": "Pilocarpine Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000915", "drug_name": "Pilocarpine Hydrochloride 5 MG Oral Tablet [Salagen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000946", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 40 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1000976", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 40 MG/ML Medicated Pad [Sumaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1001004", "drug_name": "Pilocarpine Hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1001006", "drug_name": "Pilocarpine Hydrochloride 7.5 MG Oral Tablet [Salagen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1001690", "drug_name": "Suprep Bowel Prep Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1002300", "drug_name": "nilotinib 150 MG Oral Capsule [Tasigna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1005767", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Medicated Liquid Soap [Avar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1005835", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Topical Cream [Avar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1005853", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1005856", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1005928", "drug_name": "ulipristal acetate 30 MG Oral Tablet [Ella]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006057", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 50 MG/ML Medicated Liquid Soap [Rosanil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006065", "drug_name": "Altavera 28 Day Regimen", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006105", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 20 MG/ML Medicated Liquid Soap [Avar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006110", "drug_name": "Sulfacetamide Sodium 100 MG/ML Medicated Liquid Soap [Ovace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006120", "drug_name": "Sulfacetamide Sodium 100 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006122", "drug_name": "Sulfacetamide Sodium 100 MG/ML Ophthalmic Solution [Bleph-10]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006558", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste [Clinpro 5000]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006608", "drug_name": "24 HR dexmethylphenidate hydrochloride 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006688", "drug_name": "Sulfacetamide Sodium 100 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006693", "drug_name": "Sulfacetamide Sodium 100 MG/ML Topical Lotion [Klaron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006801", "drug_name": "Clozapine 150 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1006803", "drug_name": "Clozapine 150 MG Disintegrating Oral Tablet [Fazaclo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1009145", "drug_name": "Amphetamine aspartate 1.875 MG / Amphetamine Sulfate 1.875 MG / Dextroamphetamine saccharate 1.875 MG / Dextroamphetamine Sulfate 1.875 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1009147", "drug_name": "Amphetamine aspartate 1.875 MG / Amphetamine Sulfate 1.875 MG / Dextroamphetamine saccharate 1.875 MG / Dextroamphetamine Sulfate 1.875 MG Oral Tablet [Adderall]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1009341", "drug_name": "bimatoprost 0.1 MG/ML Ophthalmic Solution [Lumigan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1009480", "drug_name": "Testosterone Propionate 100 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010600", "drug_name": "Buprenorphine 2 MG / Naloxone 0.5 MG Sublingual Film", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010603", "drug_name": "Buprenorphine 2 MG / Naloxone 0.5 MG Sublingual Film [Suboxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010604", "drug_name": "Buprenorphine 8 MG / Naloxone 2 MG Sublingual Film", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010606", "drug_name": "Buprenorphine 8 MG / Naloxone 2 MG Sublingual Film [Suboxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010630", "drug_name": "testosterone cypionate 50 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010654", "drug_name": "Methocarbamol 750 MG Oral Tablet [Robaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010836", "drug_name": "Lidocaine Hydrochloride 30 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1010878", "drug_name": "Lidocaine Hydrochloride 40 MG/ML Mucous Membrane Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011080", "drug_name": "Dexamethasone 0.5 MG/ML / Tobramycin 3 MG/ML Ophthalmic Suspension [Tobradex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011081", "drug_name": "Zarah 28-Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011703", "drug_name": "Lidocaine Hydrochloride 0.035 MG/MG Ophthalmic Gel [Akten]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011705", "drug_name": "Lidocaine 0.05 MG/MG Medicated Patch [Lidoderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011712", "drug_name": "aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011715", "drug_name": "aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011736", "drug_name": "aliskiren 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011738", "drug_name": "aliskiren 150 MG Oral Tablet [Tekturna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011739", "drug_name": "aliskiren 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011741", "drug_name": "aliskiren 300 MG Oral Tablet [Tekturna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011752", "drug_name": "aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011755", "drug_name": "aliskiren 300 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011852", "drug_name": "Lidocaine Hydrochloride 0.02 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011875", "drug_name": "Sulfacetamide Sodium 90 MG/ML / Sulfur 40 MG/ML Medicated Liquid Soap [Sumaxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1011987", "drug_name": "prednisolone acetate 0.002 MG/MG / Sulfacetamide Sodium 0.1 MG/MG Ophthalmic Ointment [Blephamide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012017", "drug_name": "prednisolone acetate 2 MG/ML / Sulfacetamide Sodium 100 MG/ML Ophthalmic Suspension [Blephamide]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012021", "drug_name": "Prednisolone sodium phosphate 2.5 MG/ML / Sulfacetamide Sodium 100 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012060", "drug_name": "10 ML Lidocaine Hydrochloride 0.02 MG/MG Prefilled Applicator", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012062", "drug_name": "20 ML Lidocaine Hydrochloride 0.02 MG/MG Prefilled Applicator", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012064", "drug_name": "5 ML Lidocaine Hydrochloride 0.02 MG/MG Prefilled Applicator", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012221", "drug_name": "hydrocortisone acetate 0.0055 MG/MG / Lidocaine Hydrochloride 0.028 MG/MG Rectal Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012223", "drug_name": "hydrocortisone acetate 0.025 MG/MG / Lidocaine Hydrochloride 0.03 MG/MG Rectal Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012229", "drug_name": "hydrocortisone acetate 10 MG/ML / Lidocaine Hydrochloride 30 MG/ML Rectal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012235", "drug_name": "hydrocortisone acetate 5 MG/ML / Lidocaine Hydrochloride 30 MG/ML Rectal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012899", "drug_name": "fingolimod 0.5 MG Oral Capsule [Gilenya]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1012904", "drug_name": "Carbinoxamine maleate 4 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1013629", "drug_name": "{24 (drospirenone 3 MG / Ethinyl Estradiol 0.02 MG / levomefolate calcium 0.451 MG Oral Tablet) / 4 (levomefolate calcium 0.451 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1013630", "drug_name": "Beyaz 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1013662", "drug_name": "24 HR Minocycline 55 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1013930", "drug_name": "12 HR Clonidine Hydrochloride 0.1 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1013934", "drug_name": "12 HR Clonidine Hydrochloride 0.1 MG Extended Release Oral Tablet [Kapvay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014018", "drug_name": "24 HR Minocycline 105 MG Extended Release Oral Tablet [Solodyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014022", "drug_name": "24 HR Minocycline 55 MG Extended Release Oral Tablet [Solodyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014024", "drug_name": "24 HR Minocycline 80 MG Extended Release Oral Tablet [Solodyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014314", "drug_name": "Triamcinolone Acetonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014583", "drug_name": "12 HR cetirizine hydrochloride 5 MG / Pseudoephedrine Hydrochloride 120 MG Extended Release Oral Tablet [Zyrtec-D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1014673", "drug_name": "cetirizine hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020026", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet [Zyrtec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020035", "drug_name": "calcipotriene 0.05 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020039", "drug_name": "calcipotriene 0.05 MG/ML Topical Foam [Sorilux]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020065", "drug_name": "{4 (risedronate sodium 35 MG Delayed Release Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020066", "drug_name": "{4 (risedronate sodium 35 MG Delayed Release Oral Tablet) } Pack [Atelvia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020155", "drug_name": "Introvale 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1020477", "drug_name": "Diphenhydramine Hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1037049", "drug_name": "dabigatran etexilate 150 MG Oral Capsule [Pradaxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1037181", "drug_name": "dabigatran etexilate 75 MG Oral Capsule [Pradaxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1037185", "drug_name": "Lo Loestrin Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1037259", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1040036", "drug_name": "Lurasidone Hydrochloride 40 MG Oral Tablet [Latuda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1040043", "drug_name": "Lurasidone Hydrochloride 80 MG Oral Tablet [Latuda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1040058", "drug_name": "Dextromethorphan Hydrobromide 20 MG / Quinidine Sulfate 10 MG Oral Capsule [Nuedexta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1041497", "drug_name": "bimatoprost 0.3 MG/ML Topical Solution [Latisse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043031", "drug_name": "Cefixime 200 MG Chewable Tablet [Suprax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043567", "drug_name": "24 HR Metformin hydrochloride 1000 MG / saxagliptin 2.5 MG Extended Release Oral Tablet [Kombiglyze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043574", "drug_name": "24 HR Metformin hydrochloride 1000 MG / saxagliptin 5 MG Extended Release Oral Tablet [Kombiglyze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043582", "drug_name": "24 HR Metformin hydrochloride 500 MG / saxagliptin 5 MG Extended Release Oral Tablet [Kombiglyze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043748", "drug_name": "azelaic acid 0.15 MG/MG Topical Gel [Finacea]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1043753", "drug_name": "azelaic acid 200 MG/ML Topical Cream [Azelex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1044591", "drug_name": "tesamorelin 2 MG Injection [Egrifta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1045404", "drug_name": "dasatinib 140 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1045408", "drug_name": "dasatinib 80 MG Oral Tablet [Sprycel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046402", "drug_name": "1.7 ML denosumab 70 MG/ML Injection [Xgeva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046770", "drug_name": "12 HR Hyoscyamine Sulfate 0.375 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046771", "drug_name": "12 HR Hyoscyamine Sulfate 0.375 MG Extended Release Oral Tablet [Levbid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046775", "drug_name": "12 HR Hyoscyamine Sulfate 0.375 MG Extended Release Oral Tablet [Symax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046787", "drug_name": "Atropine Sulfate 0.00388 MG/ML / Hyoscyamine Sulfate 0.0207 MG/ML / Phenobarbital 3.24 MG/ML / Scopolamine Hydrobromide 0.0013 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046815", "drug_name": "Atropine Sulfate 0.0194 MG / Hyoscyamine Sulfate 0.1037 MG / Phenobarbital 16.2 MG / Scopolamine Hydrobromide 0.0065 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046920", "drug_name": "Nicotine 4 MG Inhalation Solution [Nicotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046924", "drug_name": "Atropine Sulfate 0.00388 MG/ML / Hyoscyamine Sulfate 0.0207 MG/ML / Phenobarbital 3.24 MG/ML / Scopolamine Hydrobromide 0.0013 MG/ML Oral Solution [Donnatal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046978", "drug_name": "Atropine Sulfate 0.0194 MG / Hyoscyamine Sulfate 0.1037 MG / Phenobarbital 16.2 MG / Scopolamine Hydrobromide 0.0065 MG Oral Tablet [Donnatal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046982", "drug_name": "Hyoscyamine Sulfate 0.125 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046984", "drug_name": "Hyoscyamine Sulfate 0.125 MG Sublingual Tablet [Symax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046985", "drug_name": "Hyoscyamine Sulfate 0.125 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1046986", "drug_name": "Hyoscyamine Sulfate 0.125 MG Disintegrating Oral Tablet [Symax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047440", "drug_name": "1 ML Baclofen 0.05 MG/ML Prefilled Syringe [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047444", "drug_name": "20 ML Baclofen 0.5 MG/ML Injection [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047795", "drug_name": "Hyoscyamine Sulfate 0.12 MG / Methenamine 81.6 MG / Methylene blue 10.8 MG / phenyl salicylate 36.2 MG / Sodium Phosphate, Monobasic 40.8 MG Oral Tablet [Utira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047881", "drug_name": "Hyoscyamine Sulfate 0.025 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047895", "drug_name": "Hyoscyamine Sulfate 0.125 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047905", "drug_name": "Hyoscyamine Sulfate 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047907", "drug_name": "Hyoscyamine Sulfate 0.125 MG Oral Tablet [Levsin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1047908", "drug_name": "Hyoscyamine Sulfate 0.125 MG Sublingual Tablet [Levsin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048056", "drug_name": "Hyoscyamine Sulfate 0.125 MG Disintegrating Oral Tablet [Anaspaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048340", "drug_name": "Hyoscyamine Sulfate 0.12 MG / Methenamine 81 MG / Methylene blue 10.8 MG / phenyl salicylate 32.4 MG / Sodium Phosphate, Monobasic 40.8 MG Oral Tablet [Urelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048445", "drug_name": "Colestipol Hydrochloride 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048447", "drug_name": "Colestipol Hydrochloride 1000 MG Oral Tablet [Colestid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048450", "drug_name": "Colestipol Hydrochloride 5000 MG Granules for Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1048452", "drug_name": "Colestipol Hydrochloride 5000 MG Granules for Oral Suspension [Colestid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049167", "drug_name": "Pseudoephedrine Hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049214", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049216", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 10 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049221", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049223", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049225", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049227", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 7.5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049406", "drug_name": "Benzalkonium Chloride 500 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049504", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 10 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049545", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 15 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049565", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 20 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049576", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 30 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049586", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 40 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049589", "drug_name": "Ibuprofen 400 MG / Oxycodone Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049595", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 60 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049601", "drug_name": "Abuse-Deterrent 12 HR Oxycodone Hydrochloride 80 MG Extended Release Oral Tablet [Oxycontin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049604", "drug_name": "Oxycodone Hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049611", "drug_name": "Oxycodone Hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049613", "drug_name": "Oxycodone Hydrochloride 15 MG Oral Tablet [Roxicodone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049615", "drug_name": "Oxycodone Hydrochloride 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049618", "drug_name": "Oxycodone Hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049620", "drug_name": "Oxycodone Hydrochloride 30 MG Oral Tablet [Roxicodone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049621", "drug_name": "Oxycodone Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049623", "drug_name": "Oxycodone Hydrochloride 5 MG Oral Tablet [Roxicodone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049625", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 10 MG Oral Tablet [Percocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049637", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 2.5 MG Oral Tablet [Percocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049640", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 5 MG Oral Tablet [Percocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049642", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 7.5 MG Oral Tablet [Percocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049680", "drug_name": "Benzoyl Peroxide 98 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049682", "drug_name": "Benzoyl Peroxide 98 MG/ML Topical Foam [Benzefoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049683", "drug_name": "Oxycodone Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049686", "drug_name": "Oxycodone Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049696", "drug_name": "Oxycodone Hydrochloride 5 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049906", "drug_name": "Diphenhydramine Hydrochloride 2.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1049909", "drug_name": "Diphenhydramine Hydrochloride 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1050394", "drug_name": "Desoximetasone 0.0005 MG/MG Topical Ointment [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1050494", "drug_name": "Safyral 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1052660", "drug_name": "etravirine 200 MG Oral Tablet [Intelence]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053651", "drug_name": "Fentanyl 0.1 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053654", "drug_name": "Fentanyl 0.2 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053657", "drug_name": "Fentanyl 0.3 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053660", "drug_name": "Fentanyl 0.4 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053663", "drug_name": "Fentanyl 0.6 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053666", "drug_name": "Fentanyl 0.8 MG Sublingual Tablet [Abstral]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053697", "drug_name": "Nystatin 100 UNT/MG / Triamcinolone Acetonide 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1053753", "drug_name": "Nystatin 100000 UNT/ML / Triamcinolone Acetonide 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085633", "drug_name": "Triamcinolone Acetonide 0.00025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085636", "drug_name": "Triamcinolone Acetonide 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085640", "drug_name": "Triamcinolone Acetonide 0.005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085644", "drug_name": "Triamcinolone Acetonide 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085686", "drug_name": "Triamcinolone Acetonide 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085728", "drug_name": "Triamcinolone Acetonide 0.001 MG/MG Oral Paste", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085738", "drug_name": "Triamcinolone Acetonide 0.147 MG/ML Topical Spray [Kenalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085741", "drug_name": "Triamcinolone Acetonide 0.25 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085745", "drug_name": "Triamcinolone Acetonide 1 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085767", "drug_name": "Triamcinolone Acetonide 0.001 MG/MG Oral Paste [Oralone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085773", "drug_name": "Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1085798", "drug_name": "120 ACTUAT Triamcinolone Acetonide 0.055 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1086776", "drug_name": "vilazodone hydrochloride 10 MG Oral Tablet [Viibryd]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1086780", "drug_name": "vilazodone hydrochloride 20 MG Oral Tablet [Viibryd]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1086786", "drug_name": "vilazodone hydrochloride 40 MG Oral Tablet [Viibryd]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1086790", "drug_name": "Viibryd 10/20/40 30 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1086926", "drug_name": "Codeine Phosphate 1.26 MG/ML / Guaifenesin 20 MG/ML Oral Solution [Relcof C]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087249", "drug_name": "calcium ascorbate 60 MG / calcium threonate 0.8 MG / ferrous asparto glycinate 50 MG / folic acid 1 MG / polysaccharide iron complex 100 MG / succinic acid 50 MG / vitamin B12 0.025 MG Oral Capsule [Ferrex 150 Forte Plus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087389", "drug_name": "12 HR CHLORPHENIRAMINE POLISTIREX 4 MG / HYDROCODONE POLISTIREX 5 MG Extended Release Oral Capsule [TussiCaps]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087427", "drug_name": "12 HR CHLORPHENIRAMINE POLISTIREX 8 MG / HYDROCODONE POLISTIREX 10 MG Extended Release Oral Capsule [TussiCaps]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087438", "drug_name": "folic acid 1 MG / polysaccharide iron complex 150 MG / vitamin B12 0.025 MG Oral Capsule [Iferex 150 Forte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087457", "drug_name": "Hyoscyamine Sulfate 0.12 MG / Methenamine 81.6 MG / Methylene blue 10.8 MG / phenyl salicylate 36.2 MG / Sodium Phosphate, Monobasic 40.8 MG Oral Tablet [Uretron DS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1087463", "drug_name": "12 HR CHLORPHENIRAMINE POLISTIREX 1.6 MG/ML / HYDROCODONE POLISTIREX 2 MG/ML Extended Release Suspension [Tussionex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088251", "drug_name": "erlotinib 100 MG Oral Tablet [Tarceva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088253", "drug_name": "erlotinib 150 MG Oral Tablet [Tarceva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088255", "drug_name": "erlotinib 25 MG Oral Tablet [Tarceva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088772", "drug_name": "potassium bicarbonate 25 MEQ Effervescent Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088774", "drug_name": "potassium bicarbonate 25 MEQ Effervescent Oral Tablet [Effer-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088869", "drug_name": "Ascorbic Acid 250 MG / Iron Carbonyl 100 MG Oral Tablet [Icar C]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088934", "drug_name": "Chlorzoxazone 375 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088936", "drug_name": "Chlorzoxazone 750 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088953", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 3 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088965", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 3.33 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088970", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 3.75 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1088977", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 4 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1089023", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 4.29 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1089027", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 5 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1089030", "drug_name": "Codeine Phosphate 1 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Suspension [Zodryl DEC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1090641", "drug_name": "Triamcinolone Acetonide 0.0005 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1090992", "drug_name": "Ethinyl Estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091133", "drug_name": "Methylphenidate Hydrochloride 2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091135", "drug_name": "Methylphenidate Hydrochloride 2 MG/ML Oral Solution [Methylin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091137", "drug_name": "24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091139", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091143", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091145", "drug_name": "8 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091150", "drug_name": "Methylphenidate Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091155", "drug_name": "24 HR Methylphenidate Hydrochloride 18 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091157", "drug_name": "24 HR Methylphenidate Hydrochloride 18 MG Extended Release Oral Tablet [Concerta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091161", "drug_name": "24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091163", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091167", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091170", "drug_name": "24 HR Methylphenidate Hydrochloride 27 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091172", "drug_name": "24 HR Methylphenidate Hydrochloride 27 MG Extended Release Oral Tablet [Concerta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091173", "drug_name": "Methylphenidate Hydrochloride 27 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091176", "drug_name": "24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091178", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091182", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091185", "drug_name": "24 HR Methylphenidate Hydrochloride 36 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091187", "drug_name": "24 HR Methylphenidate Hydrochloride 36 MG Extended Release Oral Tablet [Concerta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091188", "drug_name": "Methylphenidate Hydrochloride 36 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091191", "drug_name": "24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091193", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091197", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091202", "drug_name": "24 HR Methylphenidate Hydrochloride 50 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091204", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 50 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091210", "drug_name": "24 HR Methylphenidate Hydrochloride 54 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091212", "drug_name": "24 HR Methylphenidate Hydrochloride 54 MG Extended Release Oral Tablet [Concerta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091213", "drug_name": "Methylphenidate Hydrochloride 54 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091218", "drug_name": "24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091220", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091225", "drug_name": "8 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091341", "drug_name": "Methylphenidate Hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091343", "drug_name": "Methylphenidate Hydrochloride 1 MG/ML Oral Solution [Methylin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091379", "drug_name": "Methylphenidate Hydrochloride 10 MG Oral Tablet [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091392", "drug_name": "Methylphenidate Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091395", "drug_name": "Methylphenidate Hydrochloride 20 MG Oral Tablet [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091488", "drug_name": "8 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Tablet [Metadate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091497", "drug_name": "Methylphenidate Hydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091500", "drug_name": "Methylphenidate Hydrochloride 5 MG Oral Tablet [Ritalin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091650", "drug_name": "azilsartan medoxomil 40 MG Oral Tablet [Edarbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091654", "drug_name": "azilsartan medoxomil 80 MG Oral Tablet [Edarbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091828", "drug_name": "Emoquette 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1091843", "drug_name": "Roflumilast 0.5 MG Oral Tablet [Daliresp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1093060", "drug_name": "Clomiphene Citrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1093062", "drug_name": "Clomiphene Citrate 50 MG Oral Tablet [Serophene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1093300", "drug_name": "Carbinoxamine maleate 0.8 MG/ML Oral Solution [Arbinoxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1094104", "drug_name": "Phenazopyridine hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1094107", "drug_name": "Phenazopyridine hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1094109", "drug_name": "Phenazopyridine hydrochloride 100 MG Oral Tablet [Pyridium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1094122", "drug_name": "Phenazopyridine hydrochloride 200 MG Oral Tablet [Pyridium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095224", "drug_name": "{21 (Ethinyl Estradiol 0.035 MG / Norethindrone 0.4 MG Chewable Tablet) / 7 (Ferrous fumarate 75 MG Chewable Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095227", "drug_name": "Levonest 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095229", "drug_name": "Flavoxate Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095283", "drug_name": "factor XIII, human 1 UNT Injection [Corifact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095362", "drug_name": "Balziva 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095712", "drug_name": "24 HR Nevirapine 400 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1095715", "drug_name": "24 HR Nevirapine 400 MG Extended Release Oral Tablet [Viramune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098125", "drug_name": "Duovisc 0.35/0.4 Viscoelastic Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098134", "drug_name": "24 HR Niacin 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098135", "drug_name": "24 HR Niacin 1000 MG Extended Release Oral Tablet [Niaspan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098140", "drug_name": "Duovisc 0.5/0.55 Viscoelastic Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098141", "drug_name": "24 HR Niacin 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098142", "drug_name": "24 HR Niacin 500 MG Extended Release Oral Tablet [Niaspan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098143", "drug_name": "24 HR Niacin 750 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098144", "drug_name": "24 HR Niacin 750 MG Extended Release Oral Tablet [Niaspan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098478", "drug_name": "Sodium Fluoride 0.55 MG / Xylitol 237 MG Chewable Tablet [Fluor a Day Chewable]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098483", "drug_name": "Sodium Fluoride 1.1 MG / Xylitol 237 MG Chewable Tablet [Fluor a Day Chewable]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098610", "drug_name": "24 HR lamotrigine 300 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098649", "drug_name": "Nefazodone hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098666", "drug_name": "Nefazodone hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098670", "drug_name": "Nefazodone hydrochloride 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098674", "drug_name": "Nefazodone hydrochloride 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1098678", "drug_name": "Nefazodone hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099026", "drug_name": "Loryna 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099052", "drug_name": "peginterferon alfa-2b 0.3 MG Injection [Sylatron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099056", "drug_name": "peginterferon alfa-2b 0.6 MG Injection [Sylatron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099060", "drug_name": "peginterferon alfa-2b 0.2 MG Injection [Sylatron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099269", "drug_name": "Syeda 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099288", "drug_name": "Desipramine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099290", "drug_name": "Desipramine Hydrochloride 10 MG Oral Tablet [Norpramin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099292", "drug_name": "Desipramine Hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099296", "drug_name": "Desipramine Hydrochloride 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099300", "drug_name": "Desipramine Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099302", "drug_name": "Desipramine Hydrochloride 25 MG Oral Tablet [Norpramin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099304", "drug_name": "Desipramine Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099316", "drug_name": "Desipramine Hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099563", "drug_name": "24 HR Divalproex Sodium 250 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099565", "drug_name": "24 HR Divalproex Sodium 250 MG Extended Release Oral Tablet [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099569", "drug_name": "24 HR Divalproex Sodium 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099571", "drug_name": "24 HR Divalproex Sodium 500 MG Extended Release Oral Tablet [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099596", "drug_name": "Divalproex Sodium 125 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099598", "drug_name": "Divalproex Sodium 125 MG Delayed Release Oral Capsule [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099625", "drug_name": "Divalproex Sodium 125 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099626", "drug_name": "Divalproex Sodium 125 MG Delayed Release Oral Tablet [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099636", "drug_name": "Guaifenesin 50 MG/ML / Pseudoephedrine Hydrochloride 7.5 MG/ML Oral Solution [Tusnel Pediatric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099678", "drug_name": "Divalproex Sodium 250 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099679", "drug_name": "Divalproex Sodium 250 MG Delayed Release Oral Tablet [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099681", "drug_name": "Valproic Acid 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099683", "drug_name": "Valproic Acid 250 MG Oral Capsule [Depakene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099687", "drug_name": "Valproic Acid 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099689", "drug_name": "Valproic Acid 50 MG/ML Oral Solution [Depakene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099808", "drug_name": "calcium acetate 133 MG/ML Oral Solution [Phoslyra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099870", "drug_name": "Divalproex Sodium 500 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099871", "drug_name": "Divalproex Sodium 500 MG Delayed Release Oral Tablet [Depakote]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1099897", "drug_name": "Generess Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100070", "drug_name": "Famotidine 26.6 MG / Ibuprofen 800 MG Oral Tablet [Duexis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100075", "drug_name": "abiraterone acetate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100079", "drug_name": "abiraterone acetate 250 MG Oral Tablet [Zytiga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100184", "drug_name": "Donepezil hydrochloride 23 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100187", "drug_name": "Donepezil hydrochloride 23 MG Oral Tablet [Aricept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1100706", "drug_name": "Linagliptin 5 MG Oral Tablet [Tradjenta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1101339", "drug_name": "gabapentin enacarbil 600 MG Extended Release Oral Tablet [Horizant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1101778", "drug_name": "Monobasic potassium phosphate 0.0408 MEQ/ML Oral Solution [K-Phos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1101938", "drug_name": "Sodium Fluoride 0.011 MG/MG Toothpaste [Dentagel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1102277", "drug_name": "Rilpivirine 25 MG Oral Tablet [Edurant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1110806", "drug_name": "Triamcinolone Acetonide 0.0005 MG/MG Topical Ointment [Trianex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111011", "drug_name": "Etonogestrel 68 MG Drug Implant [Nexplanon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111018", "drug_name": "Sapropterin dihydrochloride 100 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111020", "drug_name": "Sapropterin dihydrochloride 100 MG Powder for Oral Solution [Kuvan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111110", "drug_name": "fidaxomicin 200 MG Oral Tablet [Dificid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111263", "drug_name": "potassium bicarbonate 20 MEQ Effervescent Oral Tablet [Effer-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111267", "drug_name": "potassium bicarbonate 10 MEQ Effervescent Oral Tablet [Effer-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111335", "drug_name": "240 ACTUAT Olopatadine hydrochloride 6.65 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111337", "drug_name": "240 ACTUAT Olopatadine hydrochloride 6.65 MG/ACTUAT Nasal Inhaler [PATANASE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111339", "drug_name": "olopatadine 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111341", "drug_name": "olopatadine 1 MG/ML Ophthalmic Solution [Patanol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111343", "drug_name": "olopatadine 2 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111345", "drug_name": "olopatadine 2 MG/ML Ophthalmic Solution [Pataday]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111641", "drug_name": "1 ML glatiramer acetate 20 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1111642", "drug_name": "1 ML glatiramer acetate 20 MG/ML Prefilled Syringe [Copaxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1112224", "drug_name": "Chlorpheniramine Maleate 0.8 MG/ML / Hydrocodone Bitartrate 1 MG/ML / Pseudoephedrine Hydrochloride 12 MG/ML Oral Solution [Zutripro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1112246", "drug_name": "acrivastine 8 MG / Pseudoephedrine Hydrochloride 60 MG Oral Capsule [Semprex-D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1112250", "drug_name": "12 HR desloratadine 2.5 MG / Pseudoephedrine sulfate 120 MG Extended Release Oral Tablet [Clarinex-D]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1112687", "drug_name": "Amethia 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1112715", "drug_name": "Amethyst 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1113046", "drug_name": "amylase 15000 UNT / lipase 3000 UNT / protease 9500 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1113437", "drug_name": "Chlorpheniramine Maleate 0.4 MG/ML / Codeine Phosphate 2 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Phenylhistine DH]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1114074", "drug_name": "Vandetanib 100 MG Oral Tablet [Caprelsa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1114096", "drug_name": "Vandetanib 300 MG Oral Tablet [Caprelsa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1114135", "drug_name": "amylase 16000 UNT / lipase 3000 UNT / protease 10000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1114202", "drug_name": "rivaroxaban 10 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1114338", "drug_name": "Hydrocodone Bitartrate 1 MG/ML / Pseudoephedrine Hydrochloride 12 MG/ML Oral Solution [Rezira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115012", "drug_name": "Once-Daily gabapentin 300 MG Oral Tablet [Gralise]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115013", "drug_name": "Once-Daily gabapentin 600 MG Oral Tablet [Gralise]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115016", "drug_name": "Gralise Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115259", "drug_name": "1.5 ML Leuprolide Acetate 30 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115449", "drug_name": "1 ML Leuprolide Acetate 11.25 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115456", "drug_name": "1 ML Leuprolide Acetate 15 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115459", "drug_name": "1 ML Leuprolide Acetate 3.75 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115464", "drug_name": "1 ML Leuprolide Acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115468", "drug_name": "1.5 ML Leuprolide Acetate 15 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115471", "drug_name": "1.5 ML Leuprolide Acetate 20 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115473", "drug_name": "1.5 ML Leuprolide Acetate 7.5 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115575", "drug_name": "Fentanyl 0.1 MG/ACTUAT Metered Dose Nasal Spray [Lazanda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115579", "drug_name": "Fentanyl 0.4 MG/ACTUAT Metered Dose Nasal Spray [Lazanda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115698", "drug_name": "Oseltamivir 6 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1115700", "drug_name": "Oseltamivir 6 MG/ML Oral Suspension [Tamiflu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116150", "drug_name": "bacitracin zinc 0.4 UNT/MG / hydrocortisone acetate 0.01 MG/MG / Neomycin Sulfate 0.0035 MG/MG / Polymyxin B Sulfate 10 UNT/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116320", "drug_name": "24 HR Naproxen 375 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116331", "drug_name": "24 HR Naproxen 375 MG Extended Release Oral Tablet [Naprelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116339", "drug_name": "24 HR Naproxen 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116341", "drug_name": "24 HR Naproxen 500 MG Extended Release Oral Tablet [Naprelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116351", "drug_name": "24 HR Naproxen 750 MG Extended Release Oral Tablet [Naprelan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116639", "drug_name": "Ticagrelor 90 MG Oral Tablet [Brilinta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1116758", "drug_name": "chloroquine phosphate 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1117104", "drug_name": "amylase 136000 UNT / lipase 25000 UNT / protease 85000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1117531", "drug_name": "chloroquine phosphate 250 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1117536", "drug_name": "potassium nitrate 250 MG/ML / Silver Nitrate 750 MG/ML Medicated Pad", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1119400", "drug_name": "everolimus 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1119402", "drug_name": "everolimus 7.5 MG Oral Tablet [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1145932", "drug_name": "1 ML abatacept 125 MG/ML Prefilled Syringe [Orencia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1146692", "drug_name": "24 HR lamotrigine 250 MG Extended Release Oral Tablet [Lamictal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1147228", "drug_name": "Vemurafenib 240 MG Oral Tablet [Zelboraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1147337", "drug_name": "emtricitabine 200 MG / Rilpivirine 25 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Complera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1147793", "drug_name": "Sulfasalazine 500 MG Oral Tablet [Sulfazine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148107", "drug_name": "{6 (Azithromycin 500 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148141", "drug_name": "3 ML icatibant 10 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148145", "drug_name": "3 ML icatibant 10 MG/ML Prefilled Syringe [Firazyr]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148398", "drug_name": "Metronidazole 7.5 MG/ML Topical Cream [Rosadan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148478", "drug_name": "24 HR tramadol hydrochloride 100 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148482", "drug_name": "24 HR tramadol hydrochloride 100 MG Extended Release Oral Capsule [ConZip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148485", "drug_name": "24 HR tramadol hydrochloride 200 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148487", "drug_name": "24 HR tramadol hydrochloride 200 MG Extended Release Oral Capsule [ConZip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148491", "drug_name": "24 HR tramadol hydrochloride 300 MG Extended Release Oral Capsule [ConZip]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148502", "drug_name": "crizotinib 200 MG Oral Capsule [Xalkori]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148506", "drug_name": "crizotinib 250 MG Oral Capsule [Xalkori]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1148646", "drug_name": "28 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT Dry Powder Inhaler [Flovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149367", "drug_name": "12 HR tapentadol 100 MG Extended Release Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149370", "drug_name": "12 HR tapentadol 150 MG Extended Release Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149373", "drug_name": "12 HR tapentadol 200 MG Extended Release Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149376", "drug_name": "12 HR tapentadol 250 MG Extended Release Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149378", "drug_name": "12 HR tapentadol 50 MG Extended Release Oral Tablet [Nucynta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149617", "drug_name": "COLLAGENASE 0.25 UNT/MG Topical Ointment [Santyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149627", "drug_name": "Clorazepate Dipotassium 7.5 MG Oral Tablet [Tranxene]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149634", "drug_name": "84 HR Estradiol 0.00313 MG/HR Transdermal System [Vivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149645", "drug_name": "84 HR Estradiol 0.00313 MG/HR Transdermal System [Alora]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149663", "drug_name": "Povidone-Iodine 50 MG/ML Ophthalmic Solution [Betadine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1149667", "drug_name": "Camrese 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1150118", "drug_name": "Rheumatrex Dose Pack 8, 4 Week Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1150836", "drug_name": "Levobunolol Hydrochloride 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1150838", "drug_name": "Levobunolol Hydrochloride 5 MG/ML Ophthalmic Solution [Betagan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1150984", "drug_name": "{18 (Azithromycin 250 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1189098", "drug_name": "Chlorzoxazone 375 MG Oral Tablet [Lorzone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1189100", "drug_name": "Chlorzoxazone 750 MG Oral Tablet [Lorzone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190110", "drug_name": "Fluoxetine 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190201", "drug_name": "Acetaminophen 320.5 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Capsule [Trezix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190225", "drug_name": "120 ACTUAT Albuterol 0.1 MG/ACTUAT / Ipratropium Bromide 0.02 MG/ACTUAT Inhalation Spray [Combivent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190357", "drug_name": "deferiprone 500 MG Oral Tablet [Ferriprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190568", "drug_name": "Atropine Sulfate 0.005 MG/ML / Diphenoxylate Hydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190570", "drug_name": "Atropine Sulfate 0.01 MG/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190572", "drug_name": "Atropine Sulfate 0.025 MG / Diphenoxylate Hydrochloride 2.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190641", "drug_name": "Atropine Sulfate 0.025 MG / Diphenoxylate Hydrochloride 2.5 MG Oral Tablet [Lomotil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190655", "drug_name": "Atropine Sulfate 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190664", "drug_name": "Atropine Sulfate 10 MG/ML Ophthalmic Solution [Isopto Atropine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190740", "drug_name": "Atropine Sulfate 0.025 MG / Difenoxin hydrochloride 1 MG Oral Tablet [Motofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190955", "drug_name": "24 HR Testosterone 0.0833 MG/HR Transdermal System [Androderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1190957", "drug_name": "24 HR Testosterone 0.167 MG/HR Transdermal System [Androderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191013", "drug_name": "Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191026", "drug_name": "Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution [Alcaine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191056", "drug_name": "clobazam 10 MG Oral Tablet [Onfi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191058", "drug_name": "clobazam 20 MG Oral Tablet [Onfi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191222", "drug_name": "Naloxone Hydrochloride 0.4 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191234", "drug_name": "1 ML Naloxone Hydrochloride 0.4 MG/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191250", "drug_name": "2 ML Naloxone Hydrochloride 1 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191256", "drug_name": "Fluocinolone Acetonide 0.00025 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191260", "drug_name": "Fluocinolone Acetonide 0.00025 MG/MG Topical Ointment [Synalar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191267", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Medicated Shampoo [Capex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191301", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Otic Solution [Dermotic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191302", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191309", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Topical Oil [Derma-Smoothe FS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191310", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191313", "drug_name": "Fluocinolone Acetonide 0.1 MG/ML Topical Solution [Synalar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191315", "drug_name": "Fluocinolone Acetonide 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191319", "drug_name": "Fluocinolone Acetonide 0.25 MG/ML Topical Cream [Synalar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1191394", "drug_name": "Aloe Polysaccharide 0.01 MG/MG / hydrocortisone acetate 0.02 MG/MG / Iodoquinol 0.01 MG/MG Topical Gel [Alcortin A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1193337", "drug_name": "ruxolitinib 10 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1193341", "drug_name": "ruxolitinib 5 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1193345", "drug_name": "ruxolitinib 15 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1193349", "drug_name": "ruxolitinib 20 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1193353", "drug_name": "ruxolitinib 25 MG Oral Tablet [Jakafi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232084", "drug_name": "rivaroxaban 15 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232088", "drug_name": "rivaroxaban 20 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232194", "drug_name": "Zolpidem tartrate 1.75 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232200", "drug_name": "Zolpidem tartrate 1.75 MG Sublingual Tablet [Intermezzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232202", "drug_name": "Zolpidem tartrate 3.5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232204", "drug_name": "Zolpidem tartrate 3.5 MG Sublingual Tablet [Intermezzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232585", "drug_name": "24 HR Bupropion Hydrochloride 450 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1232591", "drug_name": "24 HR Bupropion Hydrochloride 450 MG Extended Release Oral Tablet [Forfivo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1233850", "drug_name": "Vestura 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234238", "drug_name": "1 ML Alprostadil 0.01 MG/ML Cartridge [Edex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234240", "drug_name": "1 ML Alprostadil 0.02 MG/ML Cartridge [Edex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234242", "drug_name": "1 ML Alprostadil 0.04 MG/ML Cartridge [Edex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234322", "drug_name": "hydrocortisone acetate 0.01 MG/MG / Pramoxine hydrochloride 0.01 MG/MG Topical Ointment [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234338", "drug_name": "hydrocortisone acetate 0.025 MG/MG / Pramoxine hydrochloride 0.01 MG/MG Topical Ointment [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234396", "drug_name": "hydrocortisone acetate 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Lotion [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234509", "drug_name": "hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Cream [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234514", "drug_name": "hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Lotion [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234519", "drug_name": "hydrocortisone acetate 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Cream [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234571", "drug_name": "Phenylephrine Hydrochloride 100 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234579", "drug_name": "Phenylephrine Hydrochloride 25 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234872", "drug_name": "Aspirin 356.4 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1234976", "drug_name": "Aspirin 356.4 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Capsule [Synalgos-DC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235150", "drug_name": "azilsartan medoxomil 40 MG / Chlorthalidone 12.5 MG Oral Tablet [Edarbyclor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235157", "drug_name": "azilsartan medoxomil 40 MG / Chlorthalidone 25 MG Oral Tablet [Edarbyclor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235249", "drug_name": "Lurasidone Hydrochloride 20 MG Oral Tablet [Latuda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235267", "drug_name": "CamreseLo 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235591", "drug_name": "raltegravir 100 MG Chewable Tablet [ISENTRESS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235595", "drug_name": "raltegravir 25 MG Chewable Tablet [ISENTRESS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235867", "drug_name": "Dasetta 7/7/7 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1235874", "drug_name": "Philith 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1236632", "drug_name": "darunavir 100 MG/ML Oral Suspension [Prezista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1237055", "drug_name": "Fentanyl 0.1 MG/ACTUAT Mucosal Spray [Subsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1237059", "drug_name": "Fentanyl 0.2 MG/ACTUAT Mucosal Spray [Subsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1237062", "drug_name": "Fentanyl 0.4 MG/ACTUAT Mucosal Spray [Subsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1237066", "drug_name": "Fentanyl 0.6 MG/ACTUAT Mucosal Spray [Subsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1237070", "drug_name": "Fentanyl 0.8 MG/ACTUAT Mucosal Spray [Subsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242106", "drug_name": "1 ML Meperidine Hydrochloride 100 MG/ML Cartridge [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242233", "drug_name": "lenalidomide 2.5 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242404", "drug_name": "24 HR Doxazosin 4 MG Extended Release Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242408", "drug_name": "24 HR Doxazosin 8 MG Extended Release Oral Tablet [Cardura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242503", "drug_name": "1 ML Meperidine Hydrochloride 25 MG/ML Cartridge [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242611", "drug_name": "Isotretinoin 10 MG Oral Capsule [Myorisan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242613", "drug_name": "Isotretinoin 20 MG Oral Capsule [Myorisan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242615", "drug_name": "Isotretinoin 40 MG Oral Capsule [Myorisan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242705", "drug_name": "Hyoscyamine Sulfate 0.125 MG Disintegrating Oral Tablet [Nulev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242786", "drug_name": "Alyacen 1/35 28-Day Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242787", "drug_name": "Alyacen 7/7/7 Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242804", "drug_name": "60 ACTUAT ciclesonide 0.037 MG/ACTUAT Nasal Inhaler [Zetonna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242815", "drug_name": "ingenol mebutate 0.0005 MG/MG Topical Gel [Picato]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242819", "drug_name": "ingenol mebutate 0.00015 MG/MG Topical Gel [Picato]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242968", "drug_name": "exenatide 2 MG Injection [Bydureon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1242998", "drug_name": "vismodegib 150 MG Oral Capsule [Erivedge]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243010", "drug_name": "axitinib 1 MG Oral Tablet [Inlyta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243014", "drug_name": "axitinib 5 MG Oral Tablet [Inlyta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243026", "drug_name": "Linagliptin 2.5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243033", "drug_name": "Linagliptin 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243040", "drug_name": "Linagliptin 2.5 MG / Metformin hydrochloride 850 MG Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243052", "drug_name": "ivacaftor 150 MG Oral Tablet [Kalydeco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243229", "drug_name": "Tenofovir disoproxil fumarate 250 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243326", "drug_name": "Tenofovir disoproxil fumarate 150 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243330", "drug_name": "Tenofovir disoproxil fumarate 200 MG Oral Tablet [Viread]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243346", "drug_name": "Tenofovir disoproxil fumarate 0.04 MG/MG Oral Powder [Viread]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243480", "drug_name": "Acetic Acid 0.009 MG/MG / Oxyquinoline Sulfate 0.00025 MG/MG Vaginal Gel [Fem pH]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243585", "drug_name": "Flurbiprofen sodium 0.3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243587", "drug_name": "Flurbiprofen sodium 0.3 MG/ML Ophthalmic Solution [Ocufen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243833", "drug_name": "24 HR Metformin hydrochloride 1000 MG / sitagliptin 100 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243843", "drug_name": "24 HR Metformin hydrochloride 1000 MG / sitagliptin 50 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1243848", "drug_name": "24 HR Metformin hydrochloride 500 MG / sitagliptin 50 MG Extended Release Oral Tablet [Janumet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244062", "drug_name": "0.6 ML Methylnaltrexone bromide 20 MG/ML Prefilled Syringe [Relistor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244064", "drug_name": "0.4 ML Methylnaltrexone bromide 20 MG/ML Prefilled Syringe [Relistor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244214", "drug_name": "Budesonide 3 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244215", "drug_name": "Budesonide 3 MG Delayed Release Oral Capsule [Entocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244616", "drug_name": "tafluprost 0.015 MG/ML Ophthalmic Solution [Zioptan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244632", "drug_name": "Amethia Lo 91 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244634", "drug_name": "Betamethasone valerate 1.2 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244636", "drug_name": "Betamethasone valerate 1.2 MG/ML Topical Foam [Luxiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244908", "drug_name": "Femcon FE 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1244921", "drug_name": "Brompheniramine Maleate 0.266 MG/ML / Codeine Phosphate 1.27 MG/ML / Phenylephrine Hydrochloride 0.666 MG/ML Oral Solution [M-End PE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245003", "drug_name": "eltrombopag 12.5 MG Oral Tablet [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245268", "drug_name": "Mifepristone 300 MG Oral Tablet [Korlym]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245275", "drug_name": "60 ACTUAT flunisolide 0.08 MG/ACTUAT Metered Dose Inhaler [Aerospan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245277", "drug_name": "120 ACTUAT flunisolide 0.08 MG/ACTUAT Metered Dose Inhaler [Aerospan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245420", "drug_name": "ezetimibe 10 MG / Simvastatin 10 MG Oral Tablet [Vytorin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245430", "drug_name": "ezetimibe 10 MG / Simvastatin 20 MG Oral Tablet [Vytorin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245441", "drug_name": "ezetimibe 10 MG / Simvastatin 40 MG Oral Tablet [Vytorin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245449", "drug_name": "ezetimibe 10 MG / Simvastatin 80 MG Oral Tablet [Vytorin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1245919", "drug_name": "Marlissa 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246096", "drug_name": "Naftifine hydrochloride 20 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246288", "drug_name": "120 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246290", "drug_name": "120 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler [Symbicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246304", "drug_name": "120 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246306", "drug_name": "120 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler [Symbicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246310", "drug_name": "120 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.1 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246313", "drug_name": "120 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.2 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246314", "drug_name": "60 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246315", "drug_name": "60 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler [Symbicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246316", "drug_name": "60 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246317", "drug_name": "60 ACTUAT Budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler [Symbicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246321", "drug_name": "formoterol fumarate 0.01 MG/ML Inhalation Solution [Perforomist]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246599", "drug_name": "Sodium Hyaluronate 0.002 MG/MG Topical Gel [Bionect]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246604", "drug_name": "Sodium Hyaluronate 2 MG/ML Topical Cream [Bionect]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1246677", "drug_name": "Naftifine hydrochloride 20 MG/ML Topical Cream [Naftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1248083", "drug_name": "Alendronic acid 70 MG Effervescent Oral Tablet [Binosto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1248115", "drug_name": "24 HR tramadol hydrochloride 150 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1248442", "drug_name": "imiquimod 25 MG/ML Topical Cream [Zyclara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1248846", "drug_name": "120 ACTUAT Beclomethasone Dipropionate 0.08 MG/ACTUAT Nasal Inhaler [Qnasl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1249631", "drug_name": "FLUOROMETHOLONE ACETATE 1 MG/ML Ophthalmic Suspension [Flarex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1250723", "drug_name": "etravirine 25 MG Oral Tablet [Intelence]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251192", "drug_name": "Lactulose 10000 MG Powder for Oral Solution [Kristalose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251196", "drug_name": "Lactulose 20000 MG Powder for Oral Solution [Kristalose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251290", "drug_name": "Hyoscyamine Sulfate 0.12 MG / Methenamine 81.6 MG / Methylene blue 10.8 MG / Sodium Phosphate, Monobasic 40.8 MG Oral Tablet [Urogesic Blue Reformulated Apr 2012]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251308", "drug_name": "Dextromethorphan Hydrobromide 2 MG/ML / Guaifenesin 20 MG/ML Oral Solution [Tusnel Diabetic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251323", "drug_name": "Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251334", "drug_name": "{28 (Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251335", "drug_name": "Femhrt 0.5/2.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251336", "drug_name": "{28 (Ethinyl Estradiol 0.005 MG / norethindrone acetate 1 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251495", "drug_name": "84 HR Estradiol 0.00208 MG/HR / norethindrone acetate 0.00583 MG/HR Transdermal System [Combipatch]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251501", "drug_name": "84 HR Estradiol 0.00208 MG/HR / norethindrone acetate 0.0104 MG/HR Transdermal System [Combipatch]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251596", "drug_name": "Interferon Alfa-2b 18000000 UNT Injection [Intron A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251616", "drug_name": "Butabarbital sodium 30 MG Oral Tablet [Butisol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251688", "drug_name": "Metronidazole 0.0075 MG/MG Topical Gel [Rosadan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251905", "drug_name": "Ethacrynic Acid 25 MG Oral Tablet [Edecrin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251914", "drug_name": "24 HR Rotigotine 0.0417 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251918", "drug_name": "24 HR Rotigotine 0.125 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1251922", "drug_name": "24 HR Rotigotine 0.333 MG/HR Transdermal System [Neupro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1252016", "drug_name": "Viorele 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291082", "drug_name": "hydrocortisone acetate 25 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291085", "drug_name": "hydrocortisone acetate 30 MG Rectal Suppository", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291092", "drug_name": "hydrocortisone acetate 30 MG Rectal Suppository [Proctocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291101", "drug_name": "hydrocortisone acetate 25 MG Rectal Suppository [Anucort-HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291103", "drug_name": "hydrocortisone acetate 25 MG Rectal Suppository [Anusol HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291312", "drug_name": "avanafil 100 MG Oral Tablet [Stendra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291367", "drug_name": "avanafil 200 MG Oral Tablet [Stendra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291371", "drug_name": "avanafil 50 MG Oral Tablet [Stendra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291860", "drug_name": "120 ACTUAT Azelastine hydrochloride 0.137 MG/ACTUAT / Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1291866", "drug_name": "120 ACTUAT Azelastine hydrochloride 0.137 MG/ACTUAT / Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler [Dymista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1292435", "drug_name": "0.65 ML Varicella-Zoster Virus Vaccine Live (Oka-Merck) strain 29800 UNT/ML Injection [Zostavax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293456", "drug_name": "tazarotene 1 MG/ML Topical Foam [Fabior]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293504", "drug_name": "Caffeine 100 MG / Ergotamine Tartrate 1 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293506", "drug_name": "Caffeine 100 MG / Ergotamine Tartrate 1 MG Oral Tablet [Cafergot]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293639", "drug_name": "Caffeine 100 MG / Ergotamine Tartrate 2 MG Rectal Suppository [Migergot]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293834", "drug_name": "hydrocortisone acetate 23.5 MG/ML / Pramoxine hydrochloride 10 MG/ML Rectal Cream [ZyPram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293864", "drug_name": "Ergotamine Tartrate 2 MG Sublingual Tablet [Ergomar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1293943", "drug_name": "chloroxylenol 1 MG/ML / Hydrocortisone 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Lotion [Cortane-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1294025", "drug_name": "hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Rectal Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1294128", "drug_name": "amylase 60500 UNT / lipase 16000 UNT / protease 57500 UNT Delayed Release Oral Capsule [Pertzye]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1294483", "drug_name": "amylase 30250 UNT / lipase 8000 UNT / protease 28750 UNT Delayed Release Oral Capsule [Pertzye]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1294621", "drug_name": "bismuth subcitrate 140 MG / Metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1297357", "drug_name": "Lurasidone Hydrochloride 120 MG Oral Tablet [Latuda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1297660", "drug_name": "Esomeprazole 2.5 MG Granules for Oral Suspension [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1297753", "drug_name": "Betaxolol Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1297757", "drug_name": "Betaxolol Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1297763", "drug_name": "Esomeprazole 5 MG Granules for Oral Suspension [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298066", "drug_name": "Cyclopentolate hydrochloride 10 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298088", "drug_name": "Flurazepam Hydrochloride 15 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298091", "drug_name": "Flurazepam Hydrochloride 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298099", "drug_name": "Guanidine Hydrochloride 125 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298356", "drug_name": "Cyclopentolate hydrochloride 10 MG/ML Ophthalmic Solution [Cyclogyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298360", "drug_name": "Cyclopentolate hydrochloride 2 MG/ML / Phenylephrine Hydrochloride 10 MG/ML Ophthalmic Solution [Cyclomydril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298364", "drug_name": "Cyclopentolate hydrochloride 20 MG/ML Ophthalmic Solution [Cyclogyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298366", "drug_name": "Cyclopentolate hydrochloride 5 MG/ML Ophthalmic Solution [Cyclogyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298407", "drug_name": "Guaifenesin 150 MG / Pseudoephedrine Hydrochloride 30 MG Oral Capsule [Respaire]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298427", "drug_name": "Ivermectin 5 MG/ML Topical Lotion [Sklice]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298452", "drug_name": "Butenafine hydrochloride 10 MG/ML Topical Cream [Mentax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298799", "drug_name": "Isoxsuprine Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298834", "drug_name": "Isoxsuprine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298857", "drug_name": "Maprotiline Hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298861", "drug_name": "Maprotiline Hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1298870", "drug_name": "Maprotiline Hydrochloride 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299203", "drug_name": "Isotretinoin 10 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299859", "drug_name": "Hydrochlorothiazide 12.5 MG / Moexipril hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299871", "drug_name": "Hydrochlorothiazide 12.5 MG / Moexipril hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299890", "drug_name": "Hydrochlorothiazide 25 MG / Moexipril hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299896", "drug_name": "Moexipril hydrochloride 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299897", "drug_name": "Moexipril hydrochloride 7.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299903", "drug_name": "Tiagabine hydrochloride 12 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299909", "drug_name": "Tiagabine hydrochloride 16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299967", "drug_name": "Tiagabine hydrochloride 12 MG Oral Tablet [Gabitril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299971", "drug_name": "Tiagabine hydrochloride 16 MG Oral Tablet [Gabitril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299973", "drug_name": "Tiagabine hydrochloride 2 MG Oral Tablet [Gabitril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1299978", "drug_name": "Tiagabine hydrochloride 4 MG Oral Tablet [Gabitril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300006", "drug_name": "Isotretinoin 20 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300014", "drug_name": "Isotretinoin 30 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300016", "drug_name": "Isotretinoin 40 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300272", "drug_name": "Ketoconazole 20 MG/ML Topical Foam [Ketodan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300538", "drug_name": "Dasetta 1/35 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300712", "drug_name": "lorcaserin hydrochloride 10 MG Oral Tablet [Belviq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300797", "drug_name": "24 HR mirabegron 25 MG Extended Release Oral Tablet [Myrbetriq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300803", "drug_name": "24 HR mirabegron 50 MG Extended Release Oral Tablet [Myrbetriq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1300911", "drug_name": "Wera 28-Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1301627", "drug_name": "20 ML Baclofen 1 MG/ML Injection [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1301694", "drug_name": "Ultravate X Cream Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1301696", "drug_name": "Ultravate X Ointment Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1301959", "drug_name": "Sorbitol 700 MG/ML Rectal Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302650", "drug_name": "24 HR Minocycline 45 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302664", "drug_name": "24 HR Minocycline 90 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302674", "drug_name": "24 HR Minocycline 135 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302833", "drug_name": "24 HR Phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302845", "drug_name": "24 HR Phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1302856", "drug_name": "24 HR Phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303107", "drug_name": "60 ACTUAT aclidinium bromide 0.4 MG/ACTUAT Dry Powder Inhaler [Tudorza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303131", "drug_name": "Prednisone 1 MG Delayed Release Oral Tablet [Rayos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303134", "drug_name": "Prednisone 2 MG Delayed Release Oral Tablet [Rayos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303137", "drug_name": "Prednisone 5 MG Delayed Release Oral Tablet [Rayos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303738", "drug_name": "Morphine Sulfate 40 MG Extended Release Oral Capsule [Kadian]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303890", "drug_name": "Trichloroacetic Acid 850 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1303930", "drug_name": "Levonorgestrel 1.5 MG Oral Tablet [Next Choice One Dose]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1304985", "drug_name": "icosapent ethyl 1000 MG Oral Capsule [Vascepa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1304988", "drug_name": "Falmina 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1305089", "drug_name": "Elinest 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1305268", "drug_name": "NDA201739 0.15 ML Epinephrine 1 MG/ML Auto-Injector [Auvi-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1305269", "drug_name": "NDA201739 0.3 ML Epinephrine 1 MG/ML Auto-Injector [Auvi-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1305810", "drug_name": "Citric Acid 12000 MG / Magnesium Oxide 3500 MG / picosulfate sodium 10 MG Powder for Oral Solution [Prepopik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1306298", "drug_name": "cobicistat 150 MG / elvitegravir 150 MG / emtricitabine 200 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Stribild]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1306898", "drug_name": "24 HR Hydromorphone Hydrochloride 32 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1306900", "drug_name": "24 HR Hydromorphone Hydrochloride 32 MG Extended Release Oral Tablet [Exalgo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307056", "drug_name": "Buprenorphine 4 MG / Naloxone 1 MG Sublingual Film", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307058", "drug_name": "Buprenorphine 4 MG / Naloxone 1 MG Sublingual Film [Suboxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307061", "drug_name": "Buprenorphine 12 MG / Naloxone 3 MG Sublingual Film", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307063", "drug_name": "Buprenorphine 12 MG / Naloxone 3 MG Sublingual Film [Suboxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307309", "drug_name": "enzalutamide 40 MG Oral Capsule [Xtandi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307415", "drug_name": "linaclotide 0.145 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307421", "drug_name": "linaclotide 0.29 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307427", "drug_name": "sildenafil 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307431", "drug_name": "sildenafil 10 MG/ML Oral Suspension [Revatio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307630", "drug_name": "bosutinib 100 MG Oral Tablet [Bosulif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1307635", "drug_name": "bosutinib 500 MG Oral Tablet [Bosulif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1308571", "drug_name": "24 HR rivastigmine 0.554 MG/HR Transdermal System [Exelon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310138", "drug_name": "everolimus 2 MG Tablet for Oral Suspension [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310144", "drug_name": "everolimus 3 MG Tablet for Oral Suspension [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310147", "drug_name": "everolimus 5 MG Tablet for Oral Suspension [Afinitor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310202", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Vicodin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310212", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 7.5 MG Oral Tablet [Vicodin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310270", "drug_name": "Acetaminophen 300 MG / Hydrocodone Bitartrate 10 MG Oral Tablet [Vicodin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310531", "drug_name": "teriflunomide 14 MG Oral Tablet [Aubagio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1310535", "drug_name": "teriflunomide 7 MG Oral Tablet [Aubagio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1312408", "drug_name": "regorafenib 40 MG Oral Tablet [Stivarga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1312589", "drug_name": "24 HR Methylphenidate Hydrochloride 5 MG/ML Extended Release Suspension [Quillivant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313061", "drug_name": "24 HR Phentermine 11.25 MG / topiramate 69 MG Extended Release Oral Capsule [Qsymia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313112", "drug_name": "Phenytoin 25 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313785", "drug_name": "Cysteamine 4.4 MG/ML Ophthalmic Solution [Cystaran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313884", "drug_name": "Phenytoin 25 MG/ML Oral Suspension [Dilantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313885", "drug_name": "Phenytoin 50 MG Chewable Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1313887", "drug_name": "Phenytoin 50 MG Chewable Tablet [Dilantin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1314763", "drug_name": "Tobramycin 75 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1314768", "drug_name": "Tobramycin 75 MG/ML Inhalation Solution [Bethkis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356074", "drug_name": "Kurvelo 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356563", "drug_name": "perampanel 2 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356572", "drug_name": "perampanel 4 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356576", "drug_name": "perampanel 6 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356580", "drug_name": "perampanel 8 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356584", "drug_name": "perampanel 10 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356588", "drug_name": "perampanel 12 MG Oral Tablet [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356673", "drug_name": "Benzyl Alcohol 0.05 ML/ML Topical Lotion [Ulesfia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356979", "drug_name": "84 HR Estradiol 0.00156 MG/HR Transdermal System [Minivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1356997", "drug_name": "84 HR Estradiol 0.00208 MG/HR Transdermal System [Minivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1357007", "drug_name": "84 HR Estradiol 0.00313 MG/HR Transdermal System [Minivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1357009", "drug_name": "84 HR Estradiol 0.00417 MG/HR Transdermal System [Minivelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1357547", "drug_name": "tofacitinib 5 MG Oral Tablet [Xeljanz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358765", "drug_name": "Junel Fe 1/20 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358770", "drug_name": "Loestrin Fe 1/20 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358775", "drug_name": "Microgestin Fe 1/20 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358780", "drug_name": "Junel 1/20 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358781", "drug_name": "Loestrin 1/20 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1358993", "drug_name": "Brompheniramine Maleate 0.4 MG/ML / Dextromethorphan Hydrobromide 2 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Bromfed DM]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359020", "drug_name": "Microgestin 1/20 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359022", "drug_name": "Ethinyl Estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359023", "drug_name": "{21 (Ethinyl Estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) / 7 (Ferrous fumarate 75 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359025", "drug_name": "Junel Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359026", "drug_name": "Loestrin Fe 1.5/30 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359027", "drug_name": "Microgestin Fe 1.5/30 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359028", "drug_name": "{21 (Ethinyl Estradiol 0.03 MG / norethindrone acetate 1.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359030", "drug_name": "Junel 1.5/30 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359031", "drug_name": "Loestrin 1.5/30 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359032", "drug_name": "Microgestin 1.5/30 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359107", "drug_name": "Diclofenac Sodium 50 MG / Misoprostol 0.2 MG Delayed Release Oral Tablet [Arthrotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359109", "drug_name": "Diclofenac Sodium 75 MG / Misoprostol 0.2 MG Delayed Release Oral Tablet [Arthrotec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359125", "drug_name": "Activella 0.5/0.1 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359126", "drug_name": "Estradiol 1 MG / norethindrone acetate 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359127", "drug_name": "{28 (Estradiol 1 MG / norethindrone acetate 0.5 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359128", "drug_name": "Activella 1/0.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359129", "drug_name": "Mimvey 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359133", "drug_name": "Estrostep Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359134", "drug_name": "Tilia Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359135", "drug_name": "Tri-Legest Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359271", "drug_name": "darunavir 800 MG Oral Tablet [Prezista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359615", "drug_name": "Triamcinolone Acetonide 0.055 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359779", "drug_name": "Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359858", "drug_name": "Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359859", "drug_name": "Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1359861", "drug_name": "Budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360002", "drug_name": "Hydromorphone Hydrochloride 1 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360026", "drug_name": "Budesonide 0.032 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360128", "drug_name": "Fluticasone propionate 0.05 MG/ACTUAT Nasal Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360131", "drug_name": "Lidocaine Hydrochloride 0.02 MG/MG Prefilled Applicator", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360201", "drug_name": "Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360304", "drug_name": "Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360954", "drug_name": "hydrocortisone acetate 10 MG/ML / Pramoxine hydrochloride 10 MG/ML Rectal Cream [Analpram HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1360956", "drug_name": "hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Lotion [Analpram HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361048", "drug_name": "heparin sodium, porcine 100 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361226", "drug_name": "heparin sodium, porcine 1000 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361563", "drug_name": "0.36 ML follitropin beta 833 UNT/ML Cartridge [Follistim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361569", "drug_name": "0.72 ML follitropin beta 833 UNT/ML Cartridge [Follistim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361572", "drug_name": "1.08 ML follitropin beta 833 UNT/ML Cartridge [Follistim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361574", "drug_name": "heparin sodium, porcine 20000 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361615", "drug_name": "heparin sodium, porcine 5000 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1361853", "drug_name": "0.5 ML heparin sodium, porcine 10000 UNT/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362082", "drug_name": "12 HR Aspirin 25 MG / Dipyridamole 200 MG Extended Release Oral Capsule [Aggrenox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362211", "drug_name": "hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Rectal Cream [Analpram HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362706", "drug_name": "Mexiletine Hydrochloride 150 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362712", "drug_name": "Mexiletine Hydrochloride 200 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362720", "drug_name": "Mexiletine Hydrochloride 250 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1362831", "drug_name": "heparin sodium, porcine 10000 UNT/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1363408", "drug_name": "Cometriq 140 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1363410", "drug_name": "Cometriq 100 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364114", "drug_name": "1 ML pasireotide 0.3 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364118", "drug_name": "1 ML pasireotide 0.6 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364122", "drug_name": "1 ML pasireotide 0.9 MG/ML Injection [Signifor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364358", "drug_name": "ponatinib 15 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364362", "drug_name": "ponatinib 45 MG Oral Tablet [Iclusig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364441", "drug_name": "apixaban 2.5 MG Oral Tablet [Eliquis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364447", "drug_name": "apixaban 5 MG Oral Tablet [Eliquis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364477", "drug_name": "teduglutide 5 MG Injection [Gattex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364490", "drug_name": "lomitapide 10 MG Oral Capsule [Juxtapid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364494", "drug_name": "lomitapide 20 MG Oral Capsule [Juxtapid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364498", "drug_name": "lomitapide 5 MG Oral Capsule [Juxtapid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364515", "drug_name": "Bedaquiline 100 MG Oral Tablet [Sirturo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1364581", "drug_name": "Cometriq 60 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1365660", "drug_name": "24 HR oxcarbazepine 150 MG Extended Release Oral Tablet [Oxtellar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1365847", "drug_name": "24 HR oxcarbazepine 300 MG Extended Release Oral Tablet [Oxtellar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1365850", "drug_name": "24 HR oxcarbazepine 600 MG Extended Release Oral Tablet [Oxtellar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1365866", "drug_name": "nepafenac 3 MG/ML Ophthalmic Suspension [Ilevro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1366192", "drug_name": "clobazam 2.5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1366339", "drug_name": "Levonorgestrel 0.000583 MG/HR Intrauterine System [Skyla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1366556", "drug_name": "24 HR Budesonide 9 MG Extended Release Oral Tablet [Uceris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1367410", "drug_name": "Ergocalciferol 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1367416", "drug_name": "Ergocalciferol 1.25 MG Oral Capsule [Drisdol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1367436", "drug_name": "21 DAY Ethinyl Estradiol 0.000625 MG/HR / Etonogestrel 0.005 MG/HR Vaginal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1367439", "drug_name": "21 DAY Ethinyl Estradiol 0.000625 MG/HR / Etonogestrel 0.005 MG/HR Vaginal System [NuvaRing]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1367848", "drug_name": "1 ML mipomersen sodium 200 MG/ML Prefilled Syringe [Kynamro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368006", "drug_name": "alogliptin 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368012", "drug_name": "alogliptin 25 MG Oral Tablet [Nesina]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368018", "drug_name": "alogliptin 6.25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368020", "drug_name": "alogliptin 6.25 MG Oral Tablet [Nesina]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368034", "drug_name": "alogliptin 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368036", "drug_name": "alogliptin 12.5 MG Oral Tablet [Nesina]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368072", "drug_name": "Codeine Phosphate 2 MG/ML / Guaifenesin 20 MG/ML / Pseudoephedrine Hydrochloride 6 MG/ML Oral Solution [Tusnel C]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368385", "drug_name": "alogliptin 12.5 MG / Metformin hydrochloride 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368391", "drug_name": "alogliptin 12.5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Kazano]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368392", "drug_name": "alogliptin 12.5 MG / Metformin hydrochloride 500 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368398", "drug_name": "alogliptin 12.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Kazano]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368403", "drug_name": "alogliptin 12.5 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368409", "drug_name": "alogliptin 12.5 MG / pioglitazone 15 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368410", "drug_name": "alogliptin 12.5 MG / pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368416", "drug_name": "alogliptin 12.5 MG / pioglitazone 30 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368417", "drug_name": "alogliptin 12.5 MG / pioglitazone 45 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368423", "drug_name": "alogliptin 12.5 MG / pioglitazone 45 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368424", "drug_name": "alogliptin 25 MG / pioglitazone 15 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368430", "drug_name": "alogliptin 25 MG / pioglitazone 15 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368431", "drug_name": "alogliptin 25 MG / pioglitazone 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368437", "drug_name": "alogliptin 25 MG / pioglitazone 30 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368438", "drug_name": "alogliptin 25 MG / pioglitazone 45 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368444", "drug_name": "alogliptin 25 MG / pioglitazone 45 MG Oral Tablet [Oseni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368459", "drug_name": "glycerol phenylbutyrate 1100 MG/ML Oral Solution [Ravicti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368954", "drug_name": "mesalamine 400 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1368960", "drug_name": "mesalamine 400 MG Delayed Release Oral Capsule [Delzicol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369589", "drug_name": "SULFONATED PHENOL 500 MG/ML / Sulfuric acid 300 MG/ML Medicated Pad [Debacterol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369724", "drug_name": "pomalidomide 1 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369728", "drug_name": "pomalidomide 2 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369732", "drug_name": "pomalidomide 3 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369736", "drug_name": "pomalidomide 4 MG Oral Capsule [Pomalyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369784", "drug_name": "20 ML Baclofen 0.5 MG/ML Prefilled Syringe [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369788", "drug_name": "20 ML Baclofen 1 MG/ML Prefilled Syringe [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369792", "drug_name": "20 ML Baclofen 2 MG/ML Prefilled Syringe [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1369831", "drug_name": "Clozapine 50 MG/ML Oral Suspension [Versacloz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370748", "drug_name": "hydrocortisone probutate 1 MG/ML Topical Cream [Pandel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370750", "drug_name": "hydrocortisone valerate 0.002 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370754", "drug_name": "hydrocortisone valerate 2 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370758", "drug_name": "Hydrocortisone butyrate 0.001 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370760", "drug_name": "Hydrocortisone butyrate 0.001 MG/MG Topical Ointment [Locoid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370765", "drug_name": "Hydrocortisone butyrate 1 MG/ML Topical Lotion [Locoid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370767", "drug_name": "Hydrocortisone butyrate 1 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370768", "drug_name": "Hydrocortisone butyrate 1 MG/ML Topical Solution [Locoid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370770", "drug_name": "Hydrocortisone butyrate 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370772", "drug_name": "Hydrocortisone butyrate 1 MG/ML Topical Cream [Locoid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1370982", "drug_name": "Ospemifene 60 MG Oral Tablet [Osphena]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1372873", "drug_name": "Chlorpheniramine Maleate 0.8 MG/ML / Hydrocodone Bitartrate 1 MG/ML Oral Solution [Vituz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373327", "drug_name": "amylase 180000 UNT / lipase 36000 UNT / protease 114000 UNT Delayed Release Oral Capsule [Creon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373333", "drug_name": "Isotretinoin 10 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373335", "drug_name": "Isotretinoin 20 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373337", "drug_name": "Isotretinoin 40 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373469", "drug_name": "canagliflozin 100 MG Oral Tablet [Invokana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373473", "drug_name": "canagliflozin 300 MG Oral Tablet [Invokana]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373483", "drug_name": "dimethyl fumarate 120 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373489", "drug_name": "dimethyl fumarate 120 MG Delayed Release Oral Capsule [Tecfidera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373491", "drug_name": "dimethyl fumarate 240 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373493", "drug_name": "dimethyl fumarate 240 MG Delayed Release Oral Capsule [Tecfidera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373498", "drug_name": "{14 (dimethyl fumarate 120 MG Delayed Release Oral Capsule [Tecfidera]) / 46 (dimethyl fumarate 240 MG Delayed Release Oral Capsule [Tecfidera]) } Pack [Tecfidera 30-Day Starter Pack]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373504", "drug_name": "Quartette 91-Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373745", "drug_name": "24 HR Nevirapine 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1373747", "drug_name": "24 HR Nevirapine 100 MG Extended Release Oral Tablet [Viramune]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1374574", "drug_name": "TOBI Podhaler Kit, 224", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1374776", "drug_name": "12 HR Carbinoxamine maleate 0.8 MG/ML Extended Release Suspension [Karbinal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1375922", "drug_name": "bromfenac 0.7 MG/ML Ophthalmic Solution [Prolensa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1375948", "drug_name": "doxylamine succinate 10 MG / Pyridoxine Hydrochloride 10 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1375954", "drug_name": "doxylamine succinate 10 MG / Pyridoxine Hydrochloride 10 MG Delayed Release Oral Tablet [Diclegis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1376336", "drug_name": "prednisolone acetate 10 MG/ML Ophthalmic Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1376338", "drug_name": "Desoximetasone 2.5 MG/ML Topical Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1376340", "drug_name": "Desoximetasone 2.5 MG/ML Topical Spray [Topicort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1421456", "drug_name": "Brimonidine tartrate 2 MG/ML / brinzolamide 10 MG/ML Ophthalmic Suspension [Simbrinza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1421473", "drug_name": "Cysteamine 25 MG Delayed Release Oral Capsule [Procysbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1421477", "drug_name": "Cysteamine 75 MG Delayed Release Oral Capsule [Procysbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1422081", "drug_name": "Enskyce 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1423082", "drug_name": "doxycycline hyclate 200 MG Delayed Release Oral Tablet [Doryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1423773", "drug_name": "Nimodipine 3 MG/ML Oral Solution [Nymalize]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425110", "drug_name": "trametinib 0.5 MG Oral Tablet [Mekinist]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425118", "drug_name": "trametinib 2 MG Oral Tablet [Mekinist]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425228", "drug_name": "dabrafenib 50 MG Oral Capsule [Tafinlar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425230", "drug_name": "dabrafenib 75 MG Oral Capsule [Tafinlar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425337", "drug_name": "Dextroamphetamine Sulfate 10 MG Oral Tablet [Zenzedi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1425339", "drug_name": "Dextroamphetamine Sulfate 5 MG Oral Tablet [Zenzedi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1426251", "drug_name": "Dextroamphetamine Sulfate 2.5 MG Oral Tablet [Zenzedi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1426253", "drug_name": "Dextroamphetamine Sulfate 7.5 MG Oral Tablet [Zenzedi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1426601", "drug_name": "Minastrin 24 Fe Chewable 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1428933", "drug_name": "Orsythia 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1429367", "drug_name": "lenalidomide 20 MG Oral Capsule [Revlimid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1430128", "drug_name": "Paroxetine mesylate 7.5 MG Oral Capsule [Brisdelle]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1430449", "drug_name": "Afatinib 20 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1430453", "drug_name": "Afatinib 30 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1430457", "drug_name": "Afatinib 40 MG Oral Tablet [Gilotrif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431083", "drug_name": "Buprenorphine 1.4 MG / Naloxone 0.36 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431104", "drug_name": "Buprenorphine 5.7 MG / Naloxone 1.4 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431237", "drug_name": "Lurasidone Hydrochloride 60 MG Oral Tablet [Latuda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431286", "drug_name": "Acetaminophen 300 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431977", "drug_name": "24 HR Tacrolimus 0.5 MG Extended Release Oral Capsule [Astagraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431982", "drug_name": "24 HR Tacrolimus 1 MG Extended Release Oral Capsule [Astagraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1431987", "drug_name": "24 HR Tacrolimus 5 MG Extended Release Oral Capsule [Astagraf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1432261", "drug_name": "Acetaminophen 300 MG / butalbital 50 MG / Caffeine 40 MG Oral Capsule [Fioricet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1432969", "drug_name": "168 HR Buprenorphine 0.015 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1432971", "drug_name": "168 HR Buprenorphine 0.015 MG/HR Transdermal System [BuTrans]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433223", "drug_name": "24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433229", "drug_name": "24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433235", "drug_name": "24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433241", "drug_name": "24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433250", "drug_name": "Fetzima Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433251", "drug_name": "0.5 ML Hydromorphone Hydrochloride 1 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433736", "drug_name": "Naftifine hydrochloride 0.02 MG/MG Topical Gel [Naftin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433802", "drug_name": "Acetaminophen 300 MG / butalbital 50 MG / Caffeine 40 MG / Codeine Phosphate 30 MG Oral Capsule [Fioricet with Codeine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1433879", "drug_name": "dolutegravir 50 MG Oral Tablet [Tivicay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1435115", "drug_name": "28 ACTUAT Teriparatide 0.02 MG/ACTUAT Pen Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1435117", "drug_name": "28 ACTUAT Teriparatide 0.02 MG/ACTUAT Pen Injector [Forteo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1435480", "drug_name": "24 HR Desvenlafaxine 100 MG Extended Release Oral Tablet [Khedezla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1435483", "drug_name": "24 HR Desvenlafaxine 50 MG Extended Release Oral Tablet [Khedezla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1435630", "drug_name": "Enalapril Maleate 1 MG/ML Oral Solution [Epaned]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1436245", "drug_name": "24 HR topiramate 50 MG Extended Release Oral Capsule [Trokendi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1436940", "drug_name": "selenium sulfide 23 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437280", "drug_name": "24 HR topiramate 25 MG Extended Release Oral Capsule [Trokendi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437285", "drug_name": "24 HR topiramate 100 MG Extended Release Oral Capsule [Trokendi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437290", "drug_name": "24 HR topiramate 200 MG Extended Release Oral Capsule [Trokendi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437492", "drug_name": "Rabeprazole sodium 5 MG Oral Granules [Aciphex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437702", "drug_name": "Albuterol 0.833 MG/ML / Ipratropium Bromide 0.167 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437704", "drug_name": "Albuterol 0.833 MG/ML / Ipratropium Bromide 0.167 MG/ML Inhalation Solution [DuoNeb]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437709", "drug_name": "brimonidine 0.0033 MG/MG Topical Gel [Mirvaso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437713", "drug_name": "Mechlorethamine 0.00016 MG/MG Topical Gel [Valchlor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437968", "drug_name": "Cyclophosphamide 25 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437969", "drug_name": "Cyclophosphamide 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1437975", "drug_name": "Glycopyrrolate 1.5 MG Oral Tablet [Glycate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1439894", "drug_name": "riociguat 0.5 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1439896", "drug_name": "riociguat 1 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1439899", "drug_name": "riociguat 1.5 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1439901", "drug_name": "riociguat 2 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1439903", "drug_name": "riociguat 2.5 MG Oral Tablet [Adempas]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1440936", "drug_name": "Hydrocortisone 25 MG/ML Topical Cream [Proctozone HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441407", "drug_name": "0.4 ML Methotrexate 25 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441413", "drug_name": "0.4 ML Methotrexate 37.5 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441418", "drug_name": "0.4 ML Methotrexate 50 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441424", "drug_name": "0.4 ML Methotrexate 62.5 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441530", "drug_name": "0.9 ML tocilizumab 180 MG/ML Prefilled Syringe [Actemra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1441740", "drug_name": "bazedoxifene 20 MG / Estrogens, Conjugated (USP) 0.45 MG Oral Tablet [Duavee]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442122", "drug_name": "Diclofenac 18 MG Oral Capsule [Zorvolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442128", "drug_name": "Diclofenac 35 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442130", "drug_name": "Diclofenac 35 MG Oral Capsule [Zorvolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442143", "drug_name": "Macitentan 10 MG Oral Tablet [Opsumit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442165", "drug_name": "Fenofibrate 30 MG Oral Capsule [Antara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442170", "drug_name": "Fenofibrate 90 MG Oral Capsule [Antara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442445", "drug_name": "Acetaminophen 20 MG/ML / Hydrocodone Bitartrate 0.667 MG/ML Oral Solution [Lortab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442522", "drug_name": "Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442528", "drug_name": "Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442530", "drug_name": "Hydrocodone Bitartrate 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442532", "drug_name": "Hydrocodone Bitartrate 15 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442534", "drug_name": "Hydrocodone Bitartrate 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442536", "drug_name": "Hydrocodone Bitartrate 20 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442538", "drug_name": "Hydrocodone Bitartrate 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442540", "drug_name": "Hydrocodone Bitartrate 30 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442542", "drug_name": "Hydrocodone Bitartrate 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442544", "drug_name": "Hydrocodone Bitartrate 40 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442546", "drug_name": "Hydrocodone Bitartrate 50 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442548", "drug_name": "Hydrocodone Bitartrate 50 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442590", "drug_name": "Econazole Nitrate 10 MG/ML Topical Foam [Ecoza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442681", "drug_name": "0.5 ML Tbo-filgrastim 0.6 MG/ML Prefilled Syringe [Granix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442683", "drug_name": "0.8 ML Tbo-filgrastim 0.6 MG/ML Prefilled Syringe [Granix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1442992", "drug_name": "Ibrutinib 140 MG Oral Capsule [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482513", "drug_name": "eslicarbazepine acetate 200 MG Oral Tablet [Aptiom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482517", "drug_name": "eslicarbazepine acetate 400 MG Oral Tablet [Aptiom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482523", "drug_name": "eslicarbazepine acetate 600 MG Oral Tablet [Aptiom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482527", "drug_name": "eslicarbazepine acetate 800 MG Oral Tablet [Aptiom]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482689", "drug_name": "luliconazole 10 MG/ML Topical Cream [Luzu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482807", "drug_name": "simeprevir 150 MG Oral Capsule [Olysio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482814", "drug_name": "1 ML golimumab 100 MG/ML Prefilled Syringe [Simponi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482821", "drug_name": "gabapentin enacarbil 300 MG Extended Release Oral Tablet [Horizant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482908", "drug_name": "posaconazole 100 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1482912", "drug_name": "posaconazole 100 MG Delayed Release Oral Tablet [Noxafil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483318", "drug_name": "Rabeprazole sodium 10 MG Oral Granules", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483319", "drug_name": "Rabeprazole sodium 10 MG Oral Granules [Aciphex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483340", "drug_name": "Potassium Chloride 20 MEQ Extended Release Oral Tablet [K-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483554", "drug_name": "Angeliq 0.5/1 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483558", "drug_name": "Zenchent Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483629", "drug_name": "Salicylic Acid 167 MG/ML Topical Solution [Gordofilm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483679", "drug_name": "zolmitriptan 2.5 MG/ACTUAT Nasal Spray [Zomig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1483744", "drug_name": "Naltrexone hydrochloride 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1484296", "drug_name": "sucroferric oxyhydroxide 500 MG Chewable Tablet [Velphoro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1484922", "drug_name": "sofosbuvir 400 MG Oral Tablet [Sovaldi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1484927", "drug_name": "0.5 ML Sumatriptan 8 MG/ML Jet Injector [Sumavel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486191", "drug_name": "Minocycline 75 MG Oral Capsule [Minocin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486198", "drug_name": "Moderiba 800 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486200", "drug_name": "Ribavirin 200 MG Oral Tablet [Moderiba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486203", "drug_name": "Moderiba 1200 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486687", "drug_name": "Sapropterin dihydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486691", "drug_name": "Sapropterin dihydrochloride 100 MG Oral Tablet [Kuvan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486841", "drug_name": "raltegravir 100 MG Granules for Oral Suspension [Isentress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486977", "drug_name": "dapagliflozin 10 MG Oral Tablet [Farxiga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1486981", "drug_name": "dapagliflozin 5 MG Oral Tablet [Farxiga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487076", "drug_name": "Diclofenac Sodium 20 MG/ML Topical Solution [Pennsaid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487288", "drug_name": "Acetaminophen 325 MG / Oxycodone Hydrochloride 2.5 MG Oral Tablet [Endocet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487361", "drug_name": "1 ML glatiramer acetate 40 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487363", "drug_name": "1 ML glatiramer acetate 40 MG/ML Prefilled Syringe [Copaxone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487498", "drug_name": "Moderiba 600 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487500", "drug_name": "Moderiba 1000 Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487524", "drug_name": "7 ACTUAT umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Anoro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1487528", "drug_name": "30 ACTUAT umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Anoro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488047", "drug_name": "Tretinoin 0.0008 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488103", "drug_name": "1125 MG Progesterone 0.08 MG/MG Prefilled Applicator [Crinone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488110", "drug_name": "1125 MG Progesterone 0.04 MG/MG Prefilled Applicator [Crinone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488304", "drug_name": "coagulation factor xiii a-subunit (recombinant) 1 UNT Injection [Tretten]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488617", "drug_name": "Lupaneta Pack 11.25 MG 3-Month", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488619", "drug_name": "Lupaneta Pack 3.75 MG 1-Month", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488667", "drug_name": "12 HR Treprostinil 0.125 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488671", "drug_name": "12 HR Treprostinil 0.25 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488675", "drug_name": "12 HR Treprostinil 1 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1488679", "drug_name": "12 HR Treprostinil 2.5 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490032", "drug_name": "Droxidopa 100 MG Oral Capsule [Northera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490036", "drug_name": "Droxidopa 200 MG Oral Capsule [Northera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490040", "drug_name": "Droxidopa 300 MG Oral Capsule [Northera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490065", "drug_name": "Raloxifene Hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490067", "drug_name": "Raloxifene Hydrochloride 60 MG Oral Tablet [Evista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490668", "drug_name": "120 ACTUAT Beclomethasone Dipropionate 0.08 MG/ACTUAT Metered Dose Inhaler [Qvar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490727", "drug_name": "Indomethacin 20 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1490774", "drug_name": "120 ACTUAT Beclomethasone Dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler [Qvar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1491527", "drug_name": "Indomethacin 20 MG Oral Capsule [Tivorbex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1491531", "drug_name": "Indomethacin 40 MG Oral Capsule [Tivorbex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1491624", "drug_name": "tasimelteon 20 MG Oral Capsule [Hetlioz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1491634", "drug_name": "metreleptin 5 MG/ML Injectable Solution [Myalept]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1491834", "drug_name": "12 HR Acetaminophen 325 MG / Oxycodone Hydrochloride 7.5 MG Extended Release Oral Tablet [Xartemis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1492671", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 10 MG Oral Tablet [Lorcet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1492673", "drug_name": "Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1492746", "drug_name": "apremilast 30 MG Oral Tablet [Otezla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1492748", "drug_name": "Otezla Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1493276", "drug_name": "Acyclovir 50 MG Buccal Tablet [Sitavig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1495064", "drug_name": "Propranolol Hydrochloride 4.28 MG/ML Oral Solution [Hemangeol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1495298", "drug_name": "0.4 ML Naloxone Hydrochloride 1 MG/ML Auto-Injector [Evzio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1495316", "drug_name": "Timothy grass pollen extract 2800 BAU Sublingual Tablet [Grastek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1495470", "drug_name": "short ragweed pollen extract 12 Amb a 1-U Sublingual Tablet [Ragwitek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1534805", "drug_name": "0.5 ML albiglutide 60 MG/ML Pen Injector [Tanzeum]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1534822", "drug_name": "0.5 ML albiglutide 100 MG/ML Pen Injector [Tanzeum]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1535468", "drug_name": "Ceritinib 150 MG Oral Capsule [Zykadia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536144", "drug_name": "120 ACTUAT mometasone furoate 0.1 MG/ACTUAT Metered Dose Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536148", "drug_name": "120 ACTUAT mometasone furoate 0.2 MG/ACTUAT Metered Dose Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536434", "drug_name": "Potassium Chloride 25 MEQ Effervescent Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536490", "drug_name": "mercaptopurine 20 MG/ML Oral Suspension [Purixan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536586", "drug_name": "168 HR Ethinyl Estradiol 0.00146 MG/HR / norelgestromin 0.00625 MG/HR Transdermal System [Xulane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1536604", "drug_name": "Monistat 3 Vaginal Cream and Topical Cream Combination Pack with Prefilled Applicators", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1537045", "drug_name": "vorapaxar 2.08 MG Oral Tablet [Zontivity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1537082", "drug_name": "potassium bicarbonate 25 MEQ Effervescent Oral Tablet [Klor-Con/EF]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1537116", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 5 MG Oral Tablet [Primlev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1537120", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 10 MG Oral Tablet [Primlev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1537122", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 7.5 MG Oral Tablet [Primlev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1539190", "drug_name": "Mimvey Lo 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1539762", "drug_name": "efinaconazole 100 MG/ML Topical Solution [Jublia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1539885", "drug_name": "30 ACTUAT umeclidinium 0.0625 MG/ACTUAT Dry Powder Inhaler [Incruse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1539891", "drug_name": "14 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1539893", "drug_name": "30 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1540356", "drug_name": "Hydrocortisone 25 MG/ML Topical Cream [Proctosol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1540868", "drug_name": "tedizolid phosphate 200 MG Oral Tablet [Sivextro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541099", "drug_name": "Clobetasol Propionate 0.5 MG/ML Medicated Shampoo [Clodan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541216", "drug_name": "Rheumatrex Dose Pack 12, 4 Wk Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541218", "drug_name": "Rheumatrex Dose Pack 16, 4 Wk Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541221", "drug_name": "Rheumatrex Dose Pack 20, 4 Wk Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541224", "drug_name": "Rheumatrex Dose Pack 24, 4 Wk Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541594", "drug_name": "Potassium Chloride 8 MEQ Extended Release Oral Tablet [K-Tab]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1541928", "drug_name": "sunitinib 37.5 MG Oral Capsule [Sutent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1542396", "drug_name": "Buprenorphine 2.1 MG / Naloxone 0.3 MG Buccal Film [Bunavail]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1542806", "drug_name": "hydrocortisone acetate 5 MG/ML / Neomycin 3.5 MG/ML / Polymyxin B 10000 UNT/ML Topical Cream [Cortisporin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1542997", "drug_name": "168 HR Buprenorphine 0.0075 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1542999", "drug_name": "168 HR Buprenorphine 0.0075 MG/HR Transdermal System [BuTrans]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543006", "drug_name": "amylase 15125 UNT / lipase 4000 UNT / protease 14375 UNT Delayed Release Oral Capsule [Pertzye]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543069", "drug_name": "Lidocaine 0.05 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543177", "drug_name": "tavaborole 43.5 MG/ML Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543182", "drug_name": "tavaborole 43.5 MG/ML Topical Solution [Kerydin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543207", "drug_name": "insulin, regular, human 4 UNT Inhalation Powder [Afrezza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543953", "drug_name": "doxycycline hyclate 150 MG Oral Tablet [Acticlate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1543955", "drug_name": "doxycycline hyclate 75 MG Oral Tablet [Acticlate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544383", "drug_name": "0.2 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544386", "drug_name": "0.25 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544388", "drug_name": "0.3 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544390", "drug_name": "0.35 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544394", "drug_name": "0.4 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544396", "drug_name": "0.45 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544398", "drug_name": "0.5 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544400", "drug_name": "0.55 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544402", "drug_name": "0.6 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544404", "drug_name": "0.15 ML Methotrexate 50 MG/ML Auto-Injector [Rasuvo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544471", "drug_name": "idelalisib 100 MG Oral Tablet [Zydelig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544475", "drug_name": "idelalisib 150 MG Oral Tablet [Zydelig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544490", "drug_name": "insulin, regular, human 8 UNT Inhalation Powder [Afrezza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544569", "drug_name": "Afrezza 90 Cartridge Pack - 60 (4 UNT), 30 (8 UNT)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544571", "drug_name": "Afrezza 90 Cartridge Pack - 30 (4 UNT), 60 (8 UNT)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544853", "drug_name": "Buprenorphine 4.2 MG / Naloxone 0.7 MG Buccal Film [Bunavail]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544856", "drug_name": "Buprenorphine 6.3 MG / Naloxone 1 MG Buccal Film [Bunavail]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1544918", "drug_name": "0.65 ML exenatide 3.08 MG/ML Pen Injector [Bydureon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545156", "drug_name": "canagliflozin 150 MG / Metformin hydrochloride 1000 MG Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545159", "drug_name": "canagliflozin 150 MG / Metformin hydrochloride 500 MG Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545163", "drug_name": "canagliflozin 50 MG / Metformin hydrochloride 1000 MG Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545166", "drug_name": "canagliflozin 50 MG / Metformin hydrochloride 500 MG Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545174", "drug_name": "hydrocortisone acetate 100 MG/ML Rectal Foam [Cortifoam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545664", "drug_name": "empagliflozin 10 MG Oral Tablet [Jardiance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1545668", "drug_name": "empagliflozin 25 MG Oral Tablet [Jardiance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1546189", "drug_name": "0.5 ML peginterferon beta-1a 0.25 MG/ML Prefilled Syringe [Plegridy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1546198", "drug_name": "Plegridy Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1546894", "drug_name": "abacavir 600 MG / dolutegravir 50 MG / Lamivudine 300 MG Oral Tablet [Triumeq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547110", "drug_name": "Suvorexant 10 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547114", "drug_name": "Suvorexant 15 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547118", "drug_name": "Suvorexant 20 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547231", "drug_name": "eliglustat 84 MG Oral Capsule [Cerdelga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547563", "drug_name": "Isotretinoin 25 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547567", "drug_name": "Isotretinoin 35 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547575", "drug_name": "Suvorexant 5 MG Oral Tablet [Belsomra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547582", "drug_name": "0.5 ML Streptococcus pneumoniae type 1 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 10A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 11A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 12F capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 14 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 15B capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoni", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547660", "drug_name": "30 ACTUAT fluticasone furoate 0.1 MG/ACTUAT Dry Powder Inhaler [Arnuity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547664", "drug_name": "14 ACTUAT fluticasone furoate 0.1 MG/ACTUAT Dry Powder Inhaler [Arnuity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547668", "drug_name": "14 ACTUAT fluticasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler [Arnuity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547672", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler [Arnuity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547711", "drug_name": "SULFONATED PHENOL 500 MG/ML / Sulfuric acid 300 MG/ML Mucous Membrane Topical Solution [Debacterol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547771", "drug_name": "Tetracaine hydrochloride 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547775", "drug_name": "Tetracaine hydrochloride 5 MG/ML Ophthalmic Solution [Tetcaine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547777", "drug_name": "Tetracaine hydrochloride 5 MG/ML Ophthalmic Solution [Tetravisc]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1547952", "drug_name": "Hyoscyamine Sulfate 0.12 MG / Methenamine 81.6 MG / Methylene blue 10.8 MG / phenyl salicylate 36.2 MG / Sodium Phosphate, Monobasic 40.8 MG Oral Tablet [Urin DS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1548714", "drug_name": "prednisolone acetate 10 MG/ML Ophthalmic Suspension [Omnipred]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1548724", "drug_name": "prednisolone acetate 10 MG/ML Ophthalmic Suspension [Pred Forte]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1549428", "drug_name": "amylase 218000 UNT / lipase 40000 UNT / protease 136000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1549447", "drug_name": "Lidocaine Hydrochloride 0.02 MG/MG Topical Gel [Glydo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1549683", "drug_name": "Xarelto 30-Day Starter Pack Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1550720", "drug_name": "Kentucky bluegrass pollen extract 300 IR / orchard grass pollen extract 300 IR / perennial rye grass pollen extract 300 IR / sweet vernal grass pollen extract 300 IR / Timothy grass pollen extract 300 IR Sublingual Tablet [Oralair 300]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1550940", "drug_name": "Colchicine 0.6 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1550946", "drug_name": "Colchicine 0.6 MG Oral Capsule [Mitigare]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1550964", "drug_name": "Lopreeza 0.5/0.1 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1550965", "drug_name": "Lopreeza 1/0.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551300", "drug_name": "0.5 ML dulaglutide 1.5 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551306", "drug_name": "0.5 ML dulaglutide 3 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551474", "drug_name": "12 HR Bupropion Hydrochloride 90 MG / Naltrexone hydrochloride 8 MG Extended Release Oral Tablet [Contrave]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551888", "drug_name": "0.2 ML adalimumab 50 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551923", "drug_name": "naloxegol 12.5 MG Oral Tablet [Movantik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551989", "drug_name": "elvitegravir 85 MG Oral Tablet [Vitekta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1551999", "drug_name": "cobicistat 150 MG Oral Tablet [Tybost]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1552004", "drug_name": "60 ACTUAT tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Spiriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1552009", "drug_name": "28 ACTUAT tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Spiriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1552035", "drug_name": "elvitegravir 150 MG Oral Tablet [Vitekta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1552349", "drug_name": "netupitant 300 MG / palonosetron 0.5 MG Oral Capsule [Akynzeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1591943", "drug_name": "ledipasvir 90 MG / sofosbuvir 400 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1591949", "drug_name": "ledipasvir 90 MG / sofosbuvir 400 MG Oral Tablet [Harvoni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1592285", "drug_name": "pirfenidone 267 MG Oral Capsule [Esbriet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1592748", "drug_name": "nintedanib 100 MG Oral Capsule [Ofev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1592752", "drug_name": "nintedanib 150 MG Oral Capsule [Ofev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593156", "drug_name": "antihemophilic factor, porcine B-domain truncated recombinant 1 UNT Injection [Obizur]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593731", "drug_name": "Sotalol Hydrochloride 5 MG/ML Oral Solution [Sotylize]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593775", "drug_name": "24 HR dapagliflozin 10 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593831", "drug_name": "24 HR dapagliflozin 5 MG / Metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593833", "drug_name": "24 HR dapagliflozin 5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593835", "drug_name": "24 HR dapagliflozin 10 MG / Metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1593858", "drug_name": "lisdexamfetamine dimesylate 10 MG Oral Capsule [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594334", "drug_name": "1.5 ML Follitropin Alfa 600 UNT/ML Pen Injector [Gonal F]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594352", "drug_name": "Humira Pediatric Crohn's Disease Starter Pack 40 MG/0.8 ML Prefilled Syringe (6 count)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594358", "drug_name": "Humira Pediatric Crohn's Disease Starter Package (3 count)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594418", "drug_name": "0.75 ML Follitropin Alfa 600 UNT/ML Pen Injector [Gonal F]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594432", "drug_name": "0.5 ML Follitropin Alfa 600 UNT/ML Pen Injector [Gonal F]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1594759", "drug_name": "0.4 ML Methotrexate 18.8 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595292", "drug_name": "amylase 14000 UNT / lipase 3000 UNT / protease 10000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595462", "drug_name": "amylase 42000 UNT / lipase 10000 UNT / protease 32000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595478", "drug_name": "amylase 84000 UNT / lipase 20000 UNT / protease 63000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595736", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 20 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595742", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 30 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595748", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 40 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595754", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 60 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595760", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 80 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595766", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 100 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1595772", "drug_name": "Abuse-Deterrent 24 HR Hydrocodone Bitartrate 120 MG Extended Release Oral Tablet [Hysingla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596023", "drug_name": "ferric citrate 1000 MG Oral Tablet [Auryxia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596030", "drug_name": "Tobramycin 60 MG/ML Inhalation Solution [Kitabis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596108", "drug_name": "Acetaminophen 320.5 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596445", "drug_name": "7 ACTUAT umeclidinium 0.0625 MG/ACTUAT Dry Powder Inhaler [Incruse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596778", "drug_name": "14 ACTUAT Budesonide 2 MG/ACTUAT Rectal Foam [Uceris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596780", "drug_name": "60 ACTUAT Testosterone 12.5 MG/ACTUAT Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596782", "drug_name": "60 ACTUAT Testosterone 5.5 MG/ACTUAT Nasal Gel [Natesto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1596783", "drug_name": "120 ACTUAT Testosterone 10 MG/ACTUAT Topical Gel [Fortesta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597074", "drug_name": "60 ACTUAT Testosterone 12.5 MG/ACTUAT Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597075", "drug_name": "60 ACTUAT Testosterone 20.25 MG/ACTUAT Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597076", "drug_name": "60 ACTUAT Testosterone 20.25 MG/ACTUAT Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597099", "drug_name": "0.5 ML L1 protein, Human papillomavirus type 11 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 16 Vaccine 0.12 MG/ML / L1 protein, Human papillomavirus type 18 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 31 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 33 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 45 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 52 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 58 Vaccine 0.04 MG/M", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597103", "drug_name": "0.5 ML L1 protein, Human papillomavirus type 11 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 16 Vaccine 0.12 MG/ML / L1 protein, Human papillomavirus type 18 Vaccine 0.08 MG/ML / L1 protein, Human papillomavirus type 31 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 33 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 45 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 52 Vaccine 0.04 MG/ML / L1 protein, Human papillomavirus type 58 Vaccine 0.04 MG/M", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597120", "drug_name": "1250 MG Testosterone 0.0162 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597121", "drug_name": "1250 MG Testosterone 0.0162 MG/MG Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597123", "drug_name": "2500 MG Testosterone 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597124", "drug_name": "2500 MG Testosterone 0.01 MG/MG Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597126", "drug_name": "2500 MG Testosterone 0.0162 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597127", "drug_name": "2500 MG Testosterone 0.0162 MG/MG Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597129", "drug_name": "5000 MG Testosterone 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597130", "drug_name": "5000 MG Testosterone 0.01 MG/MG Topical Gel [Androgel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597132", "drug_name": "5000 MG Testosterone 0.01 MG/MG Topical Gel [Testim]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597134", "drug_name": "5000 MG Testosterone 0.01 MG/MG Topical Gel [Vogelxo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597388", "drug_name": "Viekira Pak", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597570", "drug_name": "Buprenorphine 11.4 MG / Naloxone 2.9 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597575", "drug_name": "Buprenorphine 8.6 MG / Naloxone 2.1 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1597593", "drug_name": "Olaparib 50 MG Oral Capsule [Lynparza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598068", "drug_name": "Ivermectin 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598073", "drug_name": "Ivermectin 10 MG/ML Topical Cream [Soolantra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598268", "drug_name": "3 ML liraglutide 6 MG/ML Pen Injector [Saxenda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598284", "drug_name": "Guaifenesin 40 MG/ML / Hydrocodone Bitartrate 0.5 MG/ML Oral Solution [Obredon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598637", "drug_name": "60 ACTUAT Beclomethasone Dipropionate 0.04 MG/ACTUAT Nasal Inhaler [Qnasl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598826", "drug_name": "Benzoyl Peroxide 0.0375 MG/MG / clindamycin phosphate 0.012 MG/MG Topical Gel [Onexton]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1598989", "drug_name": "Atazanavir 50 MG Oral Powder [Reyataz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599549", "drug_name": "edoxaban 15 MG Oral Tablet [Savaysa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599553", "drug_name": "edoxaban 30 MG Oral Tablet [Savaysa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599557", "drug_name": "edoxaban 60 MG Oral Tablet [Savaysa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599797", "drug_name": "1 ML secukinumab 150 MG/ML Prefilled Syringe [Cosentyx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599841", "drug_name": "C1 esterase inhibitor (recombinant) 2100 UNT Injection [Ruconest]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599852", "drug_name": "Carbidopa 4.63 MG/ML / Levodopa 20 MG/ML Oral Suspension [Duopa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599948", "drug_name": "60 ACTUAT Testosterone 30 MG/ACTUAT Topical Solution [Axiron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1599949", "drug_name": "60 ACTUAT Testosterone 30 MG/ACTUAT Topical Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600695", "drug_name": "Amphetamine Sulfate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600698", "drug_name": "Amphetamine Sulfate 10 MG Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600700", "drug_name": "Amphetamine Sulfate 5 MG Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600710", "drug_name": "cobicistat 150 MG / darunavir 800 MG Oral Tablet [Prezcobix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600774", "drug_name": "8 HR Carbidopa 23.75 MG / Levodopa 95 MG Extended Release Oral Capsule [Rytary]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600776", "drug_name": "8 HR Carbidopa 36.25 MG / Levodopa 145 MG Extended Release Oral Capsule [Rytary]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600915", "drug_name": "8 HR Carbidopa 48.75 MG / Levodopa 195 MG Extended Release Oral Capsule [Rytary]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1600917", "drug_name": "8 HR Carbidopa 61.25 MG / Levodopa 245 MG Extended Release Oral Capsule [Rytary]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601091", "drug_name": "olopatadine 7 MG/ML Ophthalmic Solution [Pazeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601373", "drug_name": "naloxegol 25 MG Oral Tablet [Movantik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601386", "drug_name": "palbociclib 100 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601390", "drug_name": "palbociclib 125 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601394", "drug_name": "palbociclib 75 MG Oral Capsule [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1601660", "drug_name": "Atazanavir 300 MG / cobicistat 150 MG Oral Tablet [Evotaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602028", "drug_name": "14 ACTUAT Parathyroid Hormone 0.025 MG/ACTUAT Cartridge [Natpara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602034", "drug_name": "14 ACTUAT Parathyroid Hormone 0.05 MG/ACTUAT Cartridge [Natpara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602040", "drug_name": "14 ACTUAT Parathyroid Hormone 0.075 MG/ACTUAT Cartridge [Natpara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602046", "drug_name": "14 ACTUAT Parathyroid Hormone 0.1 MG/ACTUAT Cartridge [Natpara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602115", "drug_name": "empagliflozin 10 MG / Linagliptin 5 MG Oral Tablet [Glyxambi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602120", "drug_name": "empagliflozin 25 MG / Linagliptin 5 MG Oral Tablet [Glyxambi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602356", "drug_name": "Sulfacetamide Sodium 100 MG/ML / Sulfur 45 MG/ML Medicated Liquid Soap [Rosula]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602588", "drug_name": "24 HR Donepezil hydrochloride 10 MG / Memantine hydrochloride 14 MG Extended Release Oral Capsule [Namzaric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1602594", "drug_name": "24 HR Donepezil hydrochloride 10 MG / Memantine hydrochloride 28 MG Extended Release Oral Capsule [Namzaric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603361", "drug_name": "panobinostat 10 MG Oral Capsule [Farydak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603365", "drug_name": "panobinostat 15 MG Oral Capsule [Farydak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603369", "drug_name": "panobinostat 20 MG Oral Capsule [Farydak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603495", "drug_name": "72 HR Fentanyl 0.0375 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603498", "drug_name": "72 HR Fentanyl 0.0625 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1603501", "drug_name": "72 HR Fentanyl 0.0875 MG/HR Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1604350", "drug_name": "Lenvima 14 MG Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1604352", "drug_name": "Lenvima 24 MG Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1604384", "drug_name": "Lenvima 10 MG Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1604395", "drug_name": "Lenvima 20 MG Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1604544", "drug_name": "1.5 ML Insulin Glargine 300 UNT/ML Pen Injector [Toujeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605071", "drug_name": "0.5 ML FILGRASTIM-SNDZ 0.6 MG/ML Prefilled Syringe [Zarxio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605075", "drug_name": "0.8 ML FILGRASTIM-SNDZ 0.6 MG/ML Prefilled Syringe [Zarxio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605088", "drug_name": "Isotretinoin 30 MG Oral Capsule [Zenatane]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605172", "drug_name": "0.4 ML darbepoetin alfa 0.025 MG/ML Prefilled Syringe [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605257", "drug_name": "Levonorgestrel 0.000813 MG/HR Intrauterine System [Liletta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605441", "drug_name": "Benzoyl Peroxide 60 MG/ML Medicated Pad [Benzepro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1605455", "drug_name": "Otezla 28-Day Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1606347", "drug_name": "Metoprolol Tartrate 37.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1606349", "drug_name": "Metoprolol Tartrate 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1606866", "drug_name": "ivacaftor 50 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1606870", "drug_name": "ivacaftor 75 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607112", "drug_name": "30 ACTUAT aclidinium bromide 0.4 MG/ACTUAT Dry Powder Inhaler [Tudorza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607617", "drug_name": "24 HR desvenlafaxine succinate 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607619", "drug_name": "24 HR desvenlafaxine succinate 25 MG Extended Release Oral Tablet [Pristiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607784", "drug_name": "deferasirox 180 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607790", "drug_name": "deferasirox 180 MG Oral Tablet [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607792", "drug_name": "deferasirox 360 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607794", "drug_name": "deferasirox 360 MG Oral Tablet [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607796", "drug_name": "deferasirox 90 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1607798", "drug_name": "deferasirox 90 MG Oral Tablet [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1608274", "drug_name": "Cholic Acid 250 MG Oral Capsule [Cholbam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1608276", "drug_name": "Cholic Acid 50 MG Oral Capsule [Cholbam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648160", "drug_name": "Somatropin 10 MG/ML Injectable Solution [Zomacton]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648162", "drug_name": "Somatropin 5 MG/ML Injectable Solution [Zomacton]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648183", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648755", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 25 MG / Nitrofurantoin, Monohydrate 75 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648759", "drug_name": "NITROFURANTOIN, MACROCRYSTALS 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648785", "drug_name": "14 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648789", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Breo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1648999", "drug_name": "Triamcinolone Acetonide 5 MG/ML Topical Cream [Triderm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649401", "drug_name": "Doxycycline Monohydrate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649405", "drug_name": "doxycycline hyclate 50 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649429", "drug_name": "Doxycycline Monohydrate 75 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649491", "drug_name": "ivabradine 5 MG Oral Tablet [Corlanor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649495", "drug_name": "ivabradine 7.5 MG Oral Tablet [Corlanor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649593", "drug_name": "0.5 ML peginterferon beta-1a 0.25 MG/ML Auto-Injector [Plegridy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649605", "drug_name": "Plegridy Pen Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649946", "drug_name": "1 ML Filgrastim 0.3 MG/ML Injection [Neupogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649961", "drug_name": "200 ACTUAT Albuterol 0.09 MG/ACTUAT Dry Powder Inhaler [ProAir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649964", "drug_name": "1.6 ML Filgrastim 0.3 MG/ML Injection [Neupogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649988", "drug_name": "doxycycline hyclate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649990", "drug_name": "Doxycycline Monohydrate 100 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1649996", "drug_name": "0.5 ML Interferon beta-1a 0.044 MG/ML Auto-Injector [Rebif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650004", "drug_name": "0.5 ML Interferon beta-1a 0.088 MG/ML Auto-Injector [Rebif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650030", "drug_name": "Doxycycline Monohydrate 5 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650142", "drug_name": "Doxycycline Monohydrate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650143", "drug_name": "doxycycline hyclate 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650282", "drug_name": "Rebif Rebidose Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650444", "drug_name": "Doxycycline Monohydrate 150 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1650901", "drug_name": "0.5 ML Interferon beta-1a 0.06 MG/ML Auto-Injector [Avonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1651271", "drug_name": "28 ACTUAT olodaterol 0.0025 MG/ACTUAT / tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Stiolto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1651275", "drug_name": "60 ACTUAT olodaterol 0.0025 MG/ACTUAT / tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Stiolto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652093", "drug_name": "12 HR CHLORPHENIRAMINE POLISTIREX 0.8 MG/ML / CODEINE POLISTIREX 4 MG/ML Extended Release Suspension [Tuzistra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652242", "drug_name": "3 ML Insulin Lispro 200 UNT/ML Pen Injector [Humalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652634", "drug_name": "Citric Acid 1002 MG / potassium citrate 3300 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652638", "drug_name": "Citric Acid 1002 MG / potassium citrate 3300 MG Powder for Oral Solution [Cytra-K]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652639", "drug_name": "3 ML Insulin Lispro 100 UNT/ML Pen Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652640", "drug_name": "3 ML Insulin Lispro 100 UNT/ML Pen Injector [Humalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652646", "drug_name": "3 ML Insulin Lispro 100 UNT/ML Cartridge [Humalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1652673", "drug_name": "Doxycycline Monohydrate 50 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653144", "drug_name": "0.5 ML golimumab 100 MG/ML Auto-Injector [Simponi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653166", "drug_name": "1 ML golimumab 100 MG/ML Auto-Injector [Simponi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653198", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Cartridge [NovoLog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653204", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Pen Injector [NovoLog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653217", "drug_name": "Sapropterin dihydrochloride 500 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653221", "drug_name": "Sapropterin dihydrochloride 500 MG Powder for Oral Solution [Kuvan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653225", "drug_name": "1 ML Etanercept 50 MG/ML Auto-Injector [Enbrel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653243", "drug_name": "1 ML secukinumab 150 MG/ML Auto-Injector [Cosentyx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653435", "drug_name": "doxycycline hyclate 50 MG Delayed Release Oral Tablet [Doryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653470", "drug_name": "Viibryd Starter Pack 10/20 30 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653767", "drug_name": "Naproxen sodium 60 MG / Sumatriptan 10 MG Oral Tablet [Treximet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1653792", "drug_name": "eluxadoline 75 MG Oral Tablet [Viberzi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1654079", "drug_name": "0.5 ML ustekinumab 90 MG/ML Injection [Stelara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1654630", "drug_name": "1 ML glatiramer acetate 20 MG/ML Prefilled Syringe [Glatopa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1654912", "drug_name": "insulin, regular, human 12 UNT Inhalation Powder [Afrezza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1654951", "drug_name": "0.75 ML darbepoetin alfa 0.2 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1654955", "drug_name": "1 ML darbepoetin alfa 0.2 MG/ML Injection [Aranesp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1655032", "drug_name": "1 ML Buprenorphine 0.3 MG/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1655728", "drug_name": "0.8 ML adalimumab 50 MG/ML Auto-Injector [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1655934", "drug_name": "ivacaftor 125 MG / lumacaftor 200 MG Oral Tablet [ORKAMBI]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1656346", "drug_name": "sacubitril 24 MG / valsartan 26 MG Oral Tablet [Entresto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1656351", "drug_name": "sacubitril 49 MG / valsartan 51 MG Oral Tablet [Entresto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1656356", "drug_name": "sacubitril 97 MG / valsartan 103 MG Oral Tablet [Entresto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1656706", "drug_name": "Afrezza 90 Cartridge Pack - 60 (8 UNT), 30 (12 UNT)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657151", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657160", "drug_name": "0.5 ML Sumatriptan 12 MG/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657173", "drug_name": "0.5 ML Sumatriptan 8 MG/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657976", "drug_name": "4 ML tocilizumab 20 MG/ML Injection [Actemra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657980", "drug_name": "10 ML tocilizumab 20 MG/ML Injection [Actemra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1657982", "drug_name": "20 ML tocilizumab 20 MG/ML Injection [Actemra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658144", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.02 MG/ML Injection [Engerix-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658150", "drug_name": "1 ML Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Injection [Recombivax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658155", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Injection [Recombivax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658157", "drug_name": "1 ML Hepatitis B Surface Antigen Vaccine 0.02 MG/ML Injection [Engerix-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658325", "drug_name": "brexpiprazole 0.25 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658329", "drug_name": "brexpiprazole 0.5 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658333", "drug_name": "brexpiprazole 1 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658337", "drug_name": "brexpiprazole 2 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658341", "drug_name": "brexpiprazole 3 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658345", "drug_name": "brexpiprazole 4 MG Oral Tablet [Rexulti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658472", "drug_name": "0.5 ML Streptococcus pneumoniae type 1 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 10A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 11A capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 12F capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 14 capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoniae type 15B capsular polysaccharide antigen 0.05 MG/ML / Streptococcus pneumoni", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658637", "drug_name": "1 ML heparin sodium, porcine 10000 UNT/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1658659", "drug_name": "1 ML heparin sodium, porcine 1000 UNT/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659161", "drug_name": "1 ML alirocumab 150 MG/ML Auto-Injector [Praluent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659167", "drug_name": "1 ML alirocumab 150 MG/ML Prefilled Syringe [Praluent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659179", "drug_name": "1 ML alirocumab 75 MG/ML Prefilled Syringe [Praluent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659183", "drug_name": "1 ML alirocumab 75 MG/ML Auto-Injector [Praluent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659263", "drug_name": "1 ML heparin sodium, porcine 5000 UNT/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659445", "drug_name": "Hydrocortisone 25 MG/ML Topical Cream [Anusol HC]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659656", "drug_name": "ombitasvir 12.5 MG / paritaprevir 75 MG / Ritonavir 50 MG Oral Tablet [Technivie]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659803", "drug_name": "azelaic acid 150 MG/ML Topical Foam [Finacea]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659927", "drug_name": "sonidegib 200 MG Oral Capsule [Odomzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659929", "drug_name": "1 ML Naloxone Hydrochloride 0.4 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1659930", "drug_name": "Naloxone Hydrochloride 0.4 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1660001", "drug_name": "ANTI-INHIBITOR COAGULANT COMPLEX 1 UNT Injection [Feiba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1660191", "drug_name": "daclatasvir 30 MG Oral Tablet [Daklinza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1660196", "drug_name": "daclatasvir 60 MG Oral Tablet [Daklinza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1660934", "drug_name": "60 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.1 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1660938", "drug_name": "60 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.2 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661335", "drug_name": "factor VIII, human 1 UNT / von Willebrand factor, human 1 UNT Injection [Wilate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661345", "drug_name": "factor VIII, human 1 UNT / von Willebrand factor, human 1 UNT Injection [Alphanate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661352", "drug_name": "factor VIII, human 1 UNT / von Willebrand factor, human 1 UNT Injection [Humate-P]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661560", "drug_name": "TOBI Podhaler Weekly Kit, 56", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661567", "drug_name": "TOBI Podhaler Daily Kit, 8", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1661799", "drug_name": "Dichlorphenamide 50 MG Oral Tablet [Keveyis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1663728", "drug_name": "Isotretinoin 30 MG Oral Capsule [Myorisan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1663747", "drug_name": "adapalene 0.003 MG/MG / Benzoyl Peroxide 0.025 MG/MG Topical Gel [Epiduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664321", "drug_name": "empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664325", "drug_name": "empagliflozin 12.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664328", "drug_name": "empagliflozin 5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664440", "drug_name": "24 HR Tacrolimus 4 MG Extended Release Oral Tablet [Envarsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664448", "drug_name": "Oxycodone Hydrochloride 5 MG Oral Tablet [Oxaydo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664458", "drug_name": "24 HR Tacrolimus 0.75 MG Extended Release Oral Tablet [Envarsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664463", "drug_name": "24 HR Tacrolimus 1 MG Extended Release Oral Tablet [Envarsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1664634", "drug_name": "Oxycodone Hydrochloride 7.5 MG Oral Tablet [Oxaydo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665039", "drug_name": "Meperidine Hydrochloride 25 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665362", "drug_name": "24 HR Aspirin 162.5 MG Extended Release Oral Capsule [Durlaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665369", "drug_name": "empagliflozin 12.5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665473", "drug_name": "uridine triacetate 2000 MG Oral Granules [Xuriden]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665685", "drug_name": "1 ML Meperidine Hydrochloride 100 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665687", "drug_name": "1 ML Meperidine Hydrochloride 100 MG/ML Injection [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665688", "drug_name": "Meperidine Hydrochloride 100 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665692", "drug_name": "Meperidine Hydrochloride 50 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665697", "drug_name": "1 ML Meperidine Hydrochloride 50 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665698", "drug_name": "1 ML Meperidine Hydrochloride 50 MG/ML Injection [Demerol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665900", "drug_name": "1 ML evolocumab 140 MG/ML Auto-Injector [Repatha]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1665906", "drug_name": "1 ML evolocumab 140 MG/ML Prefilled Syringe [Repatha]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666314", "drug_name": "nonacog alfa 1 UNT Injection [Rixubis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666317", "drug_name": "nonacog alfa 1 UNT Injection [BeneFIX]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666323", "drug_name": "coagulation factor IX recombinant immunoglobulin G1 fusion protein 1 UNT Injection [Alprolix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666328", "drug_name": "nonacog alfa 1 UNT Injection [Ixinity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666334", "drug_name": "Ticagrelor 60 MG Oral Tablet [Brilinta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666385", "drug_name": "Buprenorphine 2.9 MG / Naloxone 0.71 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666391", "drug_name": "flibanserin 100 MG Oral Tablet [Addyi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666615", "drug_name": "20 ML Baclofen 2 MG/ML Injection [Gablofen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666620", "drug_name": "20 ML Baclofen 2 MG/ML Injection [Lioresal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666623", "drug_name": "5 ML Baclofen 2 MG/ML Injection [Lioresal]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1666837", "drug_name": "80 ACTUAT Fentanyl 0.04 MG/ACTUAT Transdermal System [Ionsys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1667666", "drug_name": "cariprazine 1.5 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1667670", "drug_name": "cariprazine 3 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1667674", "drug_name": "cariprazine 4.5 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1667678", "drug_name": "cariprazine 6 MG Oral Capsule [Vraylar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1667882", "drug_name": "60 ACTUAT tiotropium 0.00125 MG/ACTUAT Inhalation Spray [Spiriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1669873", "drug_name": "Fluorouracil 40 MG/ML Topical Cream [Tolak]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670016", "drug_name": "3 ML insulin degludec 100 UNT/ML Pen Injector [Tresiba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670023", "drug_name": "3 ML insulin degludec 200 UNT/ML Pen Injector [Tresiba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670192", "drug_name": "1 ML vitamin K1 10 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670193", "drug_name": "vitamin K1 10 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670322", "drug_name": "tipiracil 6.14 MG / Trifluridine 15 MG Oral Tablet [Lonsurf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670324", "drug_name": "tipiracil 8.19 MG / Trifluridine 20 MG Oral Tablet [Lonsurf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1670392", "drug_name": "factor IX complex 1 UNT Injection [Profilnine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1673373", "drug_name": "rolapitant 90 MG Oral Tablet [Varubi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716063", "drug_name": "Buprenorphine 0.15 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716067", "drug_name": "Buprenorphine 0.3 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716071", "drug_name": "Buprenorphine 0.45 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716075", "drug_name": "Buprenorphine 0.6 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716079", "drug_name": "Buprenorphine 0.075 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716083", "drug_name": "Buprenorphine 0.75 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716090", "drug_name": "Buprenorphine 0.9 MG Buccal Film [Belbuca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716099", "drug_name": "betamethasone dipropionate 0.643 MG/ML / calcipotriene 0.05 MG/ML Topical Foam [Enstilar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716215", "drug_name": "patiromer 8400 MG Powder for Oral Suspension [Veltassa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716219", "drug_name": "patiromer 16800 MG Powder for Oral Suspension [Veltassa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716223", "drug_name": "patiromer 25200 MG Powder for Oral Suspension [Veltassa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1716268", "drug_name": "deferiprone 100 MG/ML Oral Solution [Ferriprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1718965", "drug_name": "antihemophilic factor, human 1 UNT Injection [Hemofil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1718970", "drug_name": "antihemophilic factor, human 1 UNT Injection [Koate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1718996", "drug_name": "ANTIHEMOPHILIC FACTOR, HUMAN RECOMBINANT RESIDUES 743-1636 DELETED 1 UNT Injection [Xyntha]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719225", "drug_name": "Antihemophilic Factor, Human Recombinant 1 UNT Injection [Advate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719228", "drug_name": "Antihemophilic Factor, Human Recombinant 1 UNT Injection [Helixate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719231", "drug_name": "Antihemophilic Factor, Human Recombinant 1 UNT Injection [Kogenate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719240", "drug_name": "coagulation factor X, human 1 UNT Injection [Coagadex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719243", "drug_name": "Antihemophilic Factor, Human Recombinant 1 UNT Injection [Recombinate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719246", "drug_name": "turoctocog alfa 1 UNT Injection [Novoeight]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719611", "drug_name": "efmoroctocog alfa 1 UNT Injection [Eloctate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719646", "drug_name": "1 ML Haloperidol 5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719647", "drug_name": "Haloperidol 5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719669", "drug_name": "1 ML Haloperidol 5 MG/ML Injection [Haldol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719766", "drug_name": "eluxadoline 100 MG Oral Tablet [Viberzi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719803", "drug_name": "1 ML haloperidol decanoate 100 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719804", "drug_name": "haloperidol decanoate 100 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719847", "drug_name": "1 ML haloperidol decanoate 100 MG/ML Injection [Haldol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719862", "drug_name": "1 ML haloperidol decanoate 50 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1719863", "drug_name": "haloperidol decanoate 50 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720026", "drug_name": "1 ML haloperidol decanoate 50 MG/ML Injection [Haldol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720166", "drug_name": "ANTIHEMOPHILIC FACTOR, HUMAN RECOMBINANT RESIDUES 743-1636 DELETED 1 UNT Prefilled Syringe [Xyntha]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720268", "drug_name": "0.45 ML asfotase alfa 40 MG/ML Injection [Strensiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720272", "drug_name": "0.7 ML asfotase alfa 40 MG/ML Injection [Strensiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720276", "drug_name": "1 ML asfotase alfa 40 MG/ML Injection [Strensiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720280", "drug_name": "0.8 ML asfotase alfa 100 MG/ML Injection [Strensiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720592", "drug_name": "24 HR Amphetamine 2.5 MG/ML Extended Release Suspension [Dyanavel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720881", "drug_name": "Interferon Alfa-2b 10000000 UNT Injection [Intron A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1720953", "drug_name": "Glycopyrrolate 0.0156 MG / indacaterol 0.0275 MG Inhalation Powder [Utibron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721308", "drug_name": "Glycopyrrolate 0.0156 MG Inhalation Powder [Seebri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721571", "drug_name": "osimertinib 40 MG Oral Tablet [Tagrisso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721583", "drug_name": "osimertinib 80 MG Oral Tablet [Tagrisso]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721619", "drug_name": "cobicistat 150 MG / elvitegravir 150 MG / emtricitabine 200 MG / tenofovir alafenamide 10 MG Oral Tablet [Genvoya]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721685", "drug_name": "1 ML Epoetin Alfa 10000 UNT/ML Injection [Epogen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1721690", "drug_name": "1 ML Epoetin Alfa 10000 UNT/ML Injection [Procrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1722355", "drug_name": "meloxicam 5 MG Oral Capsule [Vivlodex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1722359", "drug_name": "meloxicam 10 MG Oral Capsule [Vivlodex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1722376", "drug_name": "Cobimetinib 20 MG Oral Tablet [Cotellic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723206", "drug_name": "2 ML Alfentanil 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723207", "drug_name": "Alfentanil 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723210", "drug_name": "5 ML Alfentanil 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723232", "drug_name": "1 ML Desmopressin Acetate 0.004 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723234", "drug_name": "1 ML Desmopressin Acetate 0.004 MG/ML Injection [DDAVP]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723478", "drug_name": "dabigatran etexilate 110 MG Oral Capsule [Pradaxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723763", "drug_name": "ixazomib 2.3 MG Oral Capsule [Ninlaro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723767", "drug_name": "ixazomib 3 MG Oral Capsule [Ninlaro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1723772", "drug_name": "ixazomib 4 MG Oral Capsule [Ninlaro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1724383", "drug_name": "1 ML Hydromorphone Hydrochloride 1 MG/ML Cartridge", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1724446", "drug_name": "Acetaminophen 325 MG / butalbital 25 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1725064", "drug_name": "Naloxone Hydrochloride 40 MG/ML Nasal Spray [Narcan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1726846", "drug_name": "0.4 ML adalimumab 100 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1727450", "drug_name": "24 HR Methylphenidate Hydrochloride 20 MG Chewable Extended Release Oral Tablet [QuilliChew]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1727485", "drug_name": "alectinib 150 MG Oral Capsule [Alecensa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728095", "drug_name": "romiplostim 0.25 MG Injection [Nplate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728099", "drug_name": "romiplostim 0.5 MG Injection [Nplate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728783", "drug_name": "10 ML Morphine Sulfate 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728785", "drug_name": "Morphine Sulfate 0.5 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728800", "drug_name": "10 ML Morphine Sulfate 1 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1728802", "drug_name": "Morphine Sulfate 1 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729013", "drug_name": "selexipag 1 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729029", "drug_name": "selexipag 1.2 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729033", "drug_name": "selexipag 1.4 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729047", "drug_name": "selexipag 1.6 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729053", "drug_name": "selexipag 0.2 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729057", "drug_name": "selexipag 0.4 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729061", "drug_name": "selexipag 0.6 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729065", "drug_name": "selexipag 0.8 MG Oral Tablet [Uptravi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729076", "drug_name": "Uptravi Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729091", "drug_name": "simoctocog alfa 1 UNT Injection [Nuwiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729419", "drug_name": "1 ML vinorelbine 10 MG/ML Injection [Navelbine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729423", "drug_name": "5 ML vinorelbine 10 MG/ML Injection [Navelbine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729511", "drug_name": "Hydrocortisone 25 MG/ML Topical Cream [Ala-Cort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729578", "drug_name": "remifentanil 1 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729581", "drug_name": "remifentanil 1 MG Injection [Ultiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729584", "drug_name": "remifentanil 2 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729586", "drug_name": "remifentanil 2 MG Injection [Ultiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729710", "drug_name": "remifentanil 5 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1729712", "drug_name": "remifentanil 5 MG Injection [Ultiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1730076", "drug_name": "1 ML Chlorpromazine hydrochloride 25 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1730077", "drug_name": "Chlorpromazine hydrochloride 25 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1730078", "drug_name": "2 ML Chlorpromazine hydrochloride 25 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731042", "drug_name": "lesinurad 200 MG Oral Tablet [Zurampic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731317", "drug_name": "3 ML insulin, regular, human 500 UNT/ML Pen Injector [Humulin R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731530", "drug_name": "1 ML Morphine Sulfate 15 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731531", "drug_name": "Morphine Sulfate 15 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731993", "drug_name": "1 ML Morphine Sulfate 10 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1731999", "drug_name": "20 ML Morphine Sulfate 10 MG/ML Injection [Infumorph]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1732006", "drug_name": "1 ML Morphine Sulfate 4 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1734642", "drug_name": "elbasvir 50 MG / grazoprevir 100 MG Oral Tablet [Zepatier]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1734930", "drug_name": "24 HR Methylphenidate Hydrochloride 30 MG Chewable Extended Release Oral Tablet [QuilliChew]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1734953", "drug_name": "24 HR Methylphenidate 40 MG Chewable Extended Release Oral Tablet [QuilliChew]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1735490", "drug_name": "2 ML Somatropin 10 MG/ML Cartridge [Nutropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1735501", "drug_name": "2 ML Somatropin 5 MG/ML Cartridge [Nutropin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1736863", "drug_name": "3 ML Insulin Glargine 100 UNT/ML Pen Injector [Basaglar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1736921", "drug_name": "1 ML paricalcitol 0.005 MG/ML Injection [Zemplar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737449", "drug_name": "10 ML Pamidronate Disodium 3 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737451", "drug_name": "10 ML Pamidronate Disodium 6 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737453", "drug_name": "10 ML Pamidronate Disodium 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737459", "drug_name": "Pamidronate Disodium 30 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737461", "drug_name": "Pamidronate Disodium 90 MG Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1737789", "drug_name": "Mebendazole 100 MG Chewable Tablet [Emverm]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738354", "drug_name": "1 ML ziconotide acetate 0.1 MG/ML Injection [Prialt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738358", "drug_name": "5 ML ziconotide acetate 0.1 MG/ML Injection [Prialt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738483", "drug_name": "Paroxetine Hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738495", "drug_name": "Paroxetine Hydrochloride 20 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738503", "drug_name": "Paroxetine Hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738511", "drug_name": "Paroxetine Hydrochloride 40 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738541", "drug_name": "Betamethasone 0.5 MG/ML Topical Spray [Sernivo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738581", "drug_name": "0.5 ML Sumatriptan 6 MG/ML Auto-Injector [Zembrace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738803", "drug_name": "24 HR Paroxetine Hydrochloride 12.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738804", "drug_name": "24 HR Paroxetine Hydrochloride 12.5 MG Extended Release Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738805", "drug_name": "24 HR Paroxetine Hydrochloride 25 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738806", "drug_name": "24 HR Paroxetine Hydrochloride 25 MG Extended Release Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738807", "drug_name": "24 HR Paroxetine Hydrochloride 37.5 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1738808", "drug_name": "24 HR Paroxetine Hydrochloride 37.5 MG Extended Release Oral Tablet [Paxil]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739337", "drug_name": "Sumatriptan 11 MG Nasal Powder [Onzetra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739766", "drug_name": "Brivaracetam 10 MG Oral Tablet [Briviact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739770", "drug_name": "Brivaracetam 100 MG Oral Tablet [Briviact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739774", "drug_name": "Brivaracetam 25 MG Oral Tablet [Briviact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739778", "drug_name": "Brivaracetam 50 MG Oral Tablet [Briviact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739782", "drug_name": "Brivaracetam 75 MG Oral Tablet [Briviact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739809", "drug_name": "24 HR Amphetamine 12.5 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739815", "drug_name": "24 HR Amphetamine 15.7 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739821", "drug_name": "24 HR Amphetamine 18.8 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739827", "drug_name": "24 HR Amphetamine 3.1 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739833", "drug_name": "24 HR Amphetamine 6.3 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1739839", "drug_name": "24 HR Amphetamine 9.4 MG Extended Release Oral Tablet [Adzenys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1740008", "drug_name": "Subsys 1200 MCG (2 x 600 MCG/ACTUAT) Mucosal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1740010", "drug_name": "Subsys 1600 MCG (2 x 800 MCG/ACTUAT) Mucosal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741049", "drug_name": "24 HR tofacitinib 11 MG Extended Release Oral Tablet [Xeljanz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741263", "drug_name": "10 ML iron sucrose 20 MG/ML Injection [Venofer]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741409", "drug_name": "antihemophilic factor (recombinant) pegylated 1 UNT Injection [Adynovate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741739", "drug_name": "emtricitabine 200 MG / Rilpivirine 25 MG / tenofovir alafenamide 25 MG Oral Tablet [Odefsey]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741747", "drug_name": "Vraylar 1.5/3 Mixed Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741905", "drug_name": "Dapsone 0.075 MG/MG Topical Gel", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1741907", "drug_name": "Dapsone 0.075 MG/MG Topical Gel [Aczone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1743279", "drug_name": "Esomeprazole 20 MG Delayed Release Oral Tablet [Nexium]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1743374", "drug_name": "Antihemophilic Factor, Human Recombinant 1 UNT Injection [Kovaltry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1743999", "drug_name": "albutrepenonacog alfa 1 UNT Injection [IDELVION]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1744003", "drug_name": "emtricitabine 100 MG / Tenofovir disoproxil fumarate 150 MG Oral Tablet [Truvada]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1744007", "drug_name": "emtricitabine 133 MG / Tenofovir disoproxil fumarate 200 MG Oral Tablet [Truvada]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1744011", "drug_name": "emtricitabine 167 MG / Tenofovir disoproxil fumarate 250 MG Oral Tablet [Truvada]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1745091", "drug_name": "Lidocaine 0.05 MG/MG Medicated Patch", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1745108", "drug_name": "1 ML ixekizumab 80 MG/ML Auto-Injector [Taltz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1745114", "drug_name": "1 ML ixekizumab 80 MG/ML Prefilled Syringe [Taltz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747181", "drug_name": "0.4 ML Methotrexate 31.3 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747187", "drug_name": "0.4 ML Methotrexate 43.8 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747194", "drug_name": "0.4 ML Methotrexate 56.3 MG/ML Auto-Injector [Otrexup]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747567", "drug_name": "venetoclax 100 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747577", "drug_name": "venetoclax 10 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747579", "drug_name": "venetoclax 50 MG Oral Tablet [Venclexta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747580", "drug_name": "Venclexta Starting Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1747697", "drug_name": "emtricitabine 200 MG / tenofovir alafenamide 25 MG Oral Tablet [Descovy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790126", "drug_name": "perampanel 0.5 MG/ML Oral Suspension [FYCOMPA]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790146", "drug_name": "bromfenac 0.75 MG/ML Ophthalmic Solution [Bromsite]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790167", "drug_name": "cabozantinib 20 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790171", "drug_name": "cabozantinib 40 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790175", "drug_name": "cabozantinib 60 MG Oral Tablet [Cabometyx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790220", "drug_name": "2 ML Doxercalciferol 0.002 MG/ML Injection [Hectorol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790317", "drug_name": "nitisinone 4 MG/ML Oral Suspension [Orfadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790329", "drug_name": "halobetasol propionate 0.5 MG/ML Topical Lotion [Ultravate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790533", "drug_name": "Abuse-Deterrent 12 HR Oxycodone 9 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790644", "drug_name": "120 ACTUAT formoterol fumarate 0.0048 MG/ACTUAT / Glycopyrrolate 0.009 MG/ACTUAT Metered Dose Inhaler [Bevespi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790679", "drug_name": "Simvastatin 4 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790886", "drug_name": "vortioxetine 10 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790890", "drug_name": "vortioxetine 20 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1790892", "drug_name": "vortioxetine 5 MG Oral Tablet [Trintellix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1791560", "drug_name": "Abuse-Deterrent 12 HR Oxycodone 13.5 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1791569", "drug_name": "Abuse-Deterrent 12 HR Oxycodone 18 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1791576", "drug_name": "Abuse-Deterrent 12 HR Oxycodone 27 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1791582", "drug_name": "Abuse-Deterrent 12 HR Oxycodone 36 MG Extended Release Oral Capsule [Xtampza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1791697", "drug_name": "pimavanserin 17 MG Oral Tablet [Nuplazid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1792377", "drug_name": "lenvatinib 4 MG Oral Capsule [Lenvima]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1792386", "drug_name": "Ciprofloxacin 3 MG/ML / Fluocinolone Acetonide 0.25 MG/ML Otic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1792391", "drug_name": "Ciprofloxacin 3 MG/ML / Fluocinolone Acetonide 0.25 MG/ML Otic Solution [Otovel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1792393", "drug_name": "Lenvima 18 MG (as lenvatinib mesylate) Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1793884", "drug_name": "daclatasvir 90 MG Oral Tablet [Daklinza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1793916", "drug_name": "0.5 ML Sumatriptan 8 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1795339", "drug_name": "1 ML Daclizumab 150 MG/ML Prefilled Syringe [Zinbryta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1795581", "drug_name": "Carbinoxamine maleate 6 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796070", "drug_name": "Acetylcysteine 2500 MG Effervescent Oral Tablet [Cetylev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796073", "drug_name": "Acetylcysteine 500 MG Effervescent Oral Tablet [Cetylev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796079", "drug_name": "dolutegravir 10 MG Oral Tablet [Tivicay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796083", "drug_name": "dolutegravir 25 MG Oral Tablet [Tivicay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796091", "drug_name": "24 HR Linagliptin 2.5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796096", "drug_name": "24 HR Linagliptin 5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Jentadueto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796384", "drug_name": "lonoctocog alfa 1 UNT Injection [Afstyla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1796665", "drug_name": "Lenvima 8 MG Daily Dose 30 Day Supply Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797113", "drug_name": "Estradiol 0.01 MG Vaginal Insert [Yuvafem]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797833", "drug_name": "Ipratropium Bromide 0.021 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797835", "drug_name": "Ipratropium Bromide 0.021 MG/ACTUAT Metered Dose Nasal Spray [Atrovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797840", "drug_name": "ciclesonide 0.037 MG/ACTUAT Metered Dose Nasal Spray [Zetonna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797843", "drug_name": "ciclesonide 0.05 MG/ACTUAT Metered Dose Nasal Spray [Omnaris]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797844", "drug_name": "Ipratropium Bromide 0.042 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797845", "drug_name": "Ipratropium Bromide 0.042 MG/ACTUAT Metered Dose Nasal Spray [Atrovent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797847", "drug_name": "Azelastine hydrochloride 0.137 MG/ACTUAT / Fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797849", "drug_name": "Azelastine hydrochloride 0.137 MG/ACTUAT / Fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Dymista]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797855", "drug_name": "Ketorolac Tromethamine 15.8 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797857", "drug_name": "Ketorolac Tromethamine 15.8 MG/ACTUAT Metered Dose Nasal Spray [Sprix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797861", "drug_name": "Desmopressin Acetate 0.15 MG/ACTUAT Metered Dose Nasal Spray [Stimate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797865", "drug_name": "mometasone furoate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797867", "drug_name": "Azelastine hydrochloride 0.137 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797870", "drug_name": "mometasone furoate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Nasonex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797872", "drug_name": "flunisolide 0.029 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797880", "drug_name": "Nafarelin 0.2 MG/ACTUAT Metered Dose Nasal Spray [Synarel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797883", "drug_name": "Azelastine hydrochloride 0.206 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797884", "drug_name": "Azelastine hydrochloride 0.206 MG/ACTUAT Metered Dose Nasal Spray [Astepro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797888", "drug_name": "Nicotine 0.5 MG/ACTUAT Metered Dose Nasal Spray [Nicotrol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797892", "drug_name": "fluticasone furoate 0.0275 MG/ACTUAT Metered Dose Nasal Spray [Veramyst]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797895", "drug_name": "Olopatadine hydrochloride 0.665 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797898", "drug_name": "Olopatadine hydrochloride 0.665 MG/ACTUAT Metered Dose Nasal Spray [PATANASE]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797902", "drug_name": "Beclomethasone Dipropionate 0.04 MG/ACTUAT Metered Dose Nasal Spray [Qnasl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797907", "drug_name": "Fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797913", "drug_name": "Triamcinolone Acetonide 0.055 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797915", "drug_name": "Triamcinolone Acetonide 0.055 MG/ACTUAT Metered Dose Nasal Spray [Nasacort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797917", "drug_name": "Beclomethasone Dipropionate 0.042 MG/ACTUAT Metered Dose Nasal Spray [Beconase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797921", "drug_name": "Beclomethasone Dipropionate 0.08 MG/ACTUAT Metered Dose Nasal Spray [Qnasl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797929", "drug_name": "Budesonide 0.032 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797931", "drug_name": "Budesonide 0.032 MG/ACTUAT Metered Dose Nasal Spray [Rhinocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1797933", "drug_name": "Fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Flonase]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1798370", "drug_name": "obeticholic acid 5 MG Oral Tablet [Ocaliva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1798375", "drug_name": "obeticholic acid 10 MG Oral Tablet [Ocaliva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1798388", "drug_name": "Afrezza Titration Pack- 90 (4 UNT), 90 (8 UNT)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799001", "drug_name": "nitisinone 20 MG Oral Capsule [Orfadin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799212", "drug_name": "sofosbuvir 400 MG / velpatasvir 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799218", "drug_name": "sofosbuvir 400 MG / velpatasvir 100 MG Oral Tablet [Epclusa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799230", "drug_name": "1 ML abatacept 125 MG/ML Auto-Injector [Orencia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799323", "drug_name": "Fenoprofen 400 MG Oral Capsule [Fenortho]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799325", "drug_name": "Fenoprofen 200 MG Oral Capsule [Fenortho]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799434", "drug_name": "Nitroglycerin 0.4 MG Sublingual Powder [Gonitro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1799654", "drug_name": "Sodium polystyrene sulfonate 250 MG/ML Oral Suspension [SPS]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801140", "drug_name": "doxycycline hyclate 120 MG Delayed Release Oral Tablet [Doryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801278", "drug_name": "Humira Psoriasis Starter Pack 40 MG/0.8 ML Pen (4 count)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801280", "drug_name": "Sugar-Free Cholestyramine Resin 4000 MG Powder for Oral Suspension [Questran]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801282", "drug_name": "Emollient hydrocortisone acetate 25 MG/ML / Pramoxine hydrochloride 10 MG/ML Topical Cream [Pramosone]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801283", "drug_name": "Emollient Fluocinonide 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801294", "drug_name": "Microencapsulated Potassium Chloride 20 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801295", "drug_name": "Microencapsulated Potassium Chloride 20 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801298", "drug_name": "Microencapsulated Potassium Chloride 10 MEQ Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801299", "drug_name": "Microencapsulated Potassium Chloride 10 MEQ Extended Release Oral Tablet [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801322", "drug_name": "3.5 ML evolocumab 120 MG/ML Cartridge [Repatha]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801519", "drug_name": "Methylnaltrexone bromide 150 MG Oral Tablet [Relistor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1801840", "drug_name": "lifitegrast 50 MG/ML Ophthalmic Solution [Xiidra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1802215", "drug_name": "Viekira XR Pak", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1803896", "drug_name": "3 ML Lixisenatide 0.1 MG/ML Pen Injector [Adlyxin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1803903", "drug_name": "Adlyxin Starter Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1805422", "drug_name": "24 HR Donepezil hydrochloride 10 MG / Memantine hydrochloride 21 MG Extended Release Oral Capsule [Namzaric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1805427", "drug_name": "24 HR Donepezil hydrochloride 10 MG / Memantine hydrochloride 7 MG Extended Release Oral Capsule [Namzaric]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806177", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806179", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806181", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806183", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806185", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806187", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806189", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806191", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806193", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 50 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806195", "drug_name": "50/50 Release 24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806197", "drug_name": "30/70 Release 24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806200", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806202", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806204", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 50 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806206", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806208", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806210", "drug_name": "40/60 Release 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806683", "drug_name": "Amabelz 0.5/0.1 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806684", "drug_name": "Amabelz 1/0.5 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806878", "drug_name": "crofelemer 125 MG Delayed Release Oral Tablet [Mytesi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806890", "drug_name": "Lisinopril 1 MG/ML Oral Solution [Qbrelis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806921", "drug_name": "amylase 61500 UNT / lipase 10500 UNT / protease 35500 UNT Delayed Release Oral Capsule [Pancreaze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806926", "drug_name": "amylase 98400 UNT / lipase 16800 UNT / protease 56800 UNT Delayed Release Oral Capsule [Pancreaze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806931", "drug_name": "amylase 83900 UNT / lipase 21000 UNT / protease 54700 UNT Delayed Release Oral Capsule [Pancreaze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806948", "drug_name": "doxycycline hyclate 50 MG Oral Tablet [Targadox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806955", "drug_name": "amylase 10850 UNT / lipase 2600 UNT / protease 6200 UNT Delayed Release Oral Capsule [Pancreaze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1806966", "drug_name": "amylase 24600 UNT / lipase 4200 UNT / protease 14200 UNT Delayed Release Oral Capsule [Pancreaze]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807628", "drug_name": "Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807631", "drug_name": "50 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807632", "drug_name": "100 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807636", "drug_name": "2 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807637", "drug_name": "10 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807638", "drug_name": "20 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807646", "drug_name": "5 ML Sodium Chloride 9 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807887", "drug_name": "Biphasic 12 HR Hyoscyamine Sulfate 0.375 MG Extended Release Oral Tablet [Symax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807888", "drug_name": "Modified 24 HR Metformin hydrochloride 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807894", "drug_name": "Osmotic 24 HR Metformin hydrochloride 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807915", "drug_name": "Modified 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1807917", "drug_name": "Osmotic 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1808552", "drug_name": "24 HR lorcaserin hydrochloride 20 MG Extended Release Oral Tablet [Belviq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1809905", "drug_name": "Taytulla 1 MG / 20 MCG 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1810304", "drug_name": "Phentermine Hydrochloride 8 MG Oral Tablet [Lomaira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1810489", "drug_name": "0.4 ML Granisetron 25 MG/ML Prefilled Syringe [Sustol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1810787", "drug_name": "Esomeprazole Strontium 49.3 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1810789", "drug_name": "Esomeprazole Strontium 24.65 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1810999", "drug_name": "24 HR canagliflozin 150 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811003", "drug_name": "24 HR canagliflozin 150 MG / Metformin hydrochloride 500 MG Extended Release Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811007", "drug_name": "24 HR canagliflozin 50 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811011", "drug_name": "24 HR canagliflozin 50 MG / Metformin hydrochloride 500 MG Extended Release Oral Tablet [Invokamet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811182", "drug_name": "icosapent ethyl 500 MG Oral Capsule [Vascepa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811631", "drug_name": "Aspirin 81 MG / Omeprazole 40 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811632", "drug_name": "Aspirin 325 MG / Omeprazole 40 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811916", "drug_name": "Aspirin 325 MG / Omeprazole 40 MG Delayed Release Oral Tablet [Yosprala]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1811918", "drug_name": "Aspirin 81 MG / Omeprazole 40 MG Delayed Release Oral Tablet [Yosprala]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812011", "drug_name": "Osmotic 24 HR Nifedipine 30 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812013", "drug_name": "Osmotic 24 HR Nifedipine 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812015", "drug_name": "Osmotic 24 HR Nifedipine 90 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812164", "drug_name": "Acetaminophen 325 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812434", "drug_name": "Soft Gelatin Methoxsalen 10 MG Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812470", "drug_name": "ivacaftor 125 MG / lumacaftor 100 MG Oral Tablet [ORKAMBI]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1812598", "drug_name": "vonicog alfa 1 UNT Injection [Vonvendi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1813112", "drug_name": "Rajani 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1855072", "drug_name": "24 HR Calcifediol 0.03 MG Extended Release Oral Capsule [Rayaldee]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1855389", "drug_name": "Levalbuterol 2.5 MG/ML Inhalation Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1855391", "drug_name": "Levalbuterol 2.5 MG/ML Inhalation Solution [Xopenex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1855730", "drug_name": "0.4 ML Naloxone Hydrochloride 5 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1855732", "drug_name": "0.4 ML Naloxone Hydrochloride 5 MG/ML Auto-Injector [Evzio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1856546", "drug_name": "Levonorgestrel 0.000729 MG/HR Intrauterine System [Kyleena]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1857913", "drug_name": "maraviroc 25 MG Oral Tablet [Selzentry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1857917", "drug_name": "maraviroc 75 MG Oral Tablet [Selzentry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1857925", "drug_name": "maraviroc 20 MG/ML Oral Solution [Selzentry]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1858267", "drug_name": "tenofovir alafenamide 25 MG Oral Tablet [Vemlidy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1858833", "drug_name": "12 HR Treprostinil 5 MG Extended Release Oral Tablet [Orenitram]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1858971", "drug_name": "Namzaric Titration Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1859000", "drug_name": "3 ML Insulin Glargine 100 UNT/ML / Lixisenatide 0.033 MG/ML Pen Injector [Soliqua]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1859501", "drug_name": "eltrombopag 25 MG Powder for Oral Suspension [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860172", "drug_name": "3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860491", "drug_name": "12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860492", "drug_name": "12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860493", "drug_name": "12 HR Hydrocodone Bitartrate 15 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860494", "drug_name": "12 HR Hydrocodone Bitartrate 15 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860495", "drug_name": "12 HR Hydrocodone Bitartrate 20 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860496", "drug_name": "12 HR Hydrocodone Bitartrate 20 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860497", "drug_name": "12 HR Hydrocodone Bitartrate 30 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860498", "drug_name": "12 HR Hydrocodone Bitartrate 30 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860499", "drug_name": "12 HR Hydrocodone Bitartrate 40 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860500", "drug_name": "12 HR Hydrocodone Bitartrate 40 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860501", "drug_name": "12 HR Hydrocodone Bitartrate 50 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1860502", "drug_name": "12 HR Hydrocodone Bitartrate 50 MG Extended Release Oral Capsule [Zohydro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862102", "drug_name": "Afrezza 180 Inhalation Cartridge Titration Pack - 60 (4 UNT), 60 (8 UNT), 60 (12 UNT)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862590", "drug_name": "rucaparib 300 MG Oral Tablet [Rubraca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862595", "drug_name": "rucaparib 200 MG Oral Tablet [Rubraca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862688", "drug_name": "24 HR empagliflozin 10 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862692", "drug_name": "24 HR empagliflozin 12.5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862697", "drug_name": "24 HR empagliflozin 25 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1862701", "drug_name": "24 HR empagliflozin 5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Synjardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1864414", "drug_name": "Buprenorphine 0.7 MG / Naloxone 0.18 MG Sublingual Tablet [Zubsolv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1865144", "drug_name": "Hydrocortisone 10 MG/ML Topical Cream [Proctocort]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1865295", "drug_name": "Chorionic Gonadotropin 5000 UNT/ML Injectable Solution [Novarel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1865962", "drug_name": "crisaborole 0.02 MG/MG Topical Ointment [Eucrisa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1866543", "drug_name": "1 ML Nalbuphine Hydrochloride 10 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1866551", "drug_name": "1 ML Nalbuphine Hydrochloride 20 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1867544", "drug_name": "Potassium Chloride 20 MEQ Powder for Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1867547", "drug_name": "Potassium Chloride 20 MEQ Powder for Oral Solution [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1867554", "drug_name": "Potassium Chloride 25 MEQ Powder for Oral Solution [Klor-Con]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1868020", "drug_name": "pirfenidone 801 MG Oral Tablet [Esbriet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1869699", "drug_name": "linaclotide 0.072 MG Oral Capsule [Linzess]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1869821", "drug_name": "Oxymetazoline hydrochloride 10 MG/ML Topical Cream [Rhofade]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1869883", "drug_name": "Carbinoxamine maleate 6 MG Oral Tablet [Ryvent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870205", "drug_name": "NDA201739 0.3 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870207", "drug_name": "NDA019430 0.3 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870225", "drug_name": "NDA020800 0.15 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870230", "drug_name": "NDA020800 0.3 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870232", "drug_name": "NDA201739 0.15 ML Epinephrine 1 MG/ML Auto-Injector", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870950", "drug_name": "deflazacort 6 MG Oral Tablet [Emflaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870952", "drug_name": "deflazacort 30 MG Oral Tablet [Emflaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870956", "drug_name": "deflazacort 18 MG Oral Tablet [Emflaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870960", "drug_name": "deflazacort 36 MG Oral Tablet [Emflaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1870968", "drug_name": "deflazacort 22.75 MG/ML Oral Suspension [Emflaza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871440", "drug_name": "Abuse-Deterrent 12 HR Morphine Sulfate 15 MG Extended Release Oral Tablet [Arymo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871443", "drug_name": "Abuse-Deterrent 12 HR Morphine Sulfate 30 MG Extended Release Oral Tablet [Arymo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871446", "drug_name": "Abuse-Deterrent 12 HR Morphine Sulfate 60 MG Extended Release Oral Tablet [Arymo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871459", "drug_name": "lisdexamfetamine dimesylate 40 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871461", "drug_name": "lisdexamfetamine dimesylate 30 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871463", "drug_name": "lisdexamfetamine dimesylate 20 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871465", "drug_name": "lisdexamfetamine dimesylate 10 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871467", "drug_name": "lisdexamfetamine dimesylate 60 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1871469", "drug_name": "lisdexamfetamine dimesylate 50 MG Chewable Tablet [Vyvanse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1872261", "drug_name": "1.5 ML brodalumab 140 MG/ML Prefilled Syringe [Siliq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1872458", "drug_name": "telotristat ethyl 250 MG Oral Tablet [Xermelo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1872972", "drug_name": "Lidocaine Hydrochloride 0.04 MG/MG Topical Gel [Tranzarel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1872980", "drug_name": "0.4 ML adalimumab 100 MG/ML Auto-Injector [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1873704", "drug_name": "Mibelas 24 Fe Chewable 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1873765", "drug_name": "plecanatide 3 MG Oral Tablet [Trulance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1873991", "drug_name": "Kisqali 200 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1873993", "drug_name": "Kisqali 400 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1873995", "drug_name": "Kisqali 600 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1874130", "drug_name": "Desmopressin Acetate 0.00083 MG/ACTUAT Metered Dose Nasal Spray [Noctiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1874553", "drug_name": "24 HR desvenlafaxine succinate 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1874559", "drug_name": "24 HR desvenlafaxine succinate 50 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1876406", "drug_name": "2 ML dupilumab 150 MG/ML Prefilled Syringe [Dupixent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1876609", "drug_name": "naldemedine 0.2 MG Oral Tablet [Symproic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1876916", "drug_name": "deutetrabenazine 12 MG Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1876920", "drug_name": "deutetrabenazine 6 MG Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1876924", "drug_name": "deutetrabenazine 9 MG Oral Tablet [Austedo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918044", "drug_name": "abiraterone acetate 500 MG Oral Tablet [Zytiga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918194", "drug_name": "60 ACTUAT fluticasone propionate 0.113 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918199", "drug_name": "60 ACTUAT fluticasone propionate 0.113 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918203", "drug_name": "60 ACTUAT fluticasone propionate 0.232 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918205", "drug_name": "60 ACTUAT fluticasone propionate 0.232 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918209", "drug_name": "60 ACTUAT fluticasone propionate 0.055 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918211", "drug_name": "60 ACTUAT fluticasone propionate 0.055 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918230", "drug_name": "valbenazine 40 MG Oral Capsule [Ingrezza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1918242", "drug_name": "niraparib 100 MG Oral Capsule [Zejula]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1919094", "drug_name": "midostaurin 25 MG Oral Capsule [Rydapt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921010", "drug_name": "0.1 ML adalimumab 100 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921017", "drug_name": "0.2 ML adalimumab 100 MG/ML Prefilled Syringe [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921081", "drug_name": "1.56 ML abaloparatide 2 MG/ML Pen Injector [Tymlos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921228", "drug_name": "brigatinib 30 MG Oral Tablet [Alunbrig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921466", "drug_name": "0.4 ML adalimumab 100 MG/ML Pen Injector [Humira]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921589", "drug_name": "rucaparib 250 MG Oral Tablet [Rubraca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1921598", "drug_name": "Methotrexate 2.5 MG/ML Oral Solution [Xatmep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922472", "drug_name": "safinamide 50 MG Oral Tablet [Xadago]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922476", "drug_name": "safinamide 100 MG Oral Tablet [Xadago]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922720", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922721", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 120 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922763", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922764", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 160 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922765", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922766", "drug_name": "Atrial Fibrillation Sotalol Hydrochloride 80 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922784", "drug_name": "Preservative-Free dorzolamide 20 MG/ML / Timolol 5 MG/ML Ophthalmic Solution [Cosopt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922877", "drug_name": "Preservative-Free Timolol 2.5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1922895", "drug_name": "Preservative-Free Timolol 5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923049", "drug_name": "Levothyroxine Sodium 0.175 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923052", "drug_name": "Levothyroxine Sodium 0.2 MG Oral Capsule [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923054", "drug_name": "Kisqali 200 MG - Femara 2.5 MG Daily Dose Carton", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923056", "drug_name": "Kisqali 400 MG - Femara 2.5 MG Daily Dose Carton", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923058", "drug_name": "Kisqali 600 MG - Femara 2.5 MG Daily Dose Carton", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923326", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Lotion [Nolix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923338", "drug_name": "1.14 ML sarilumab 132 MG/ML Prefilled Syringe [Kevzara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923347", "drug_name": "1.14 ML sarilumab 175 MG/ML Prefilled Syringe [Kevzara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923422", "drug_name": "Sotalol Hydrochloride 120 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923423", "drug_name": "Sotalol Hydrochloride 120 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923424", "drug_name": "Sotalol Hydrochloride 160 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923425", "drug_name": "Sotalol Hydrochloride 160 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923426", "drug_name": "Sotalol Hydrochloride 80 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923427", "drug_name": "Sotalol Hydrochloride 80 MG Oral Tablet [Betapace]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923428", "drug_name": "Timolol 2.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923429", "drug_name": "Timolol 2.5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923430", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923431", "drug_name": "Timolol 5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923432", "drug_name": "dorzolamide 20 MG/ML / Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923433", "drug_name": "dorzolamide 20 MG/ML / Timolol 5 MG/ML Ophthalmic Solution [Cosopt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923809", "drug_name": "thyroid (USP) 120 MG Oral Tablet [NP Thyroid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923822", "drug_name": "deferasirox 90 MG Oral Granules", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923825", "drug_name": "deferasirox 90 MG Oral Granules [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923826", "drug_name": "deferasirox 360 MG Oral Granules", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923827", "drug_name": "deferasirox 360 MG Oral Granules [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923828", "drug_name": "deferasirox 180 MG Oral Granules", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1923829", "drug_name": "deferasirox 180 MG Oral Granules [Jadenu]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1924315", "drug_name": "raltegravir 600 MG Oral Tablet [Isentress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1925255", "drug_name": "0.4 ML abatacept 125 MG/ML Prefilled Syringe [Orencia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1925257", "drug_name": "0.7 ML abatacept 125 MG/ML Prefilled Syringe [Orencia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1925504", "drug_name": "dapagliflozin 10 MG / saxagliptin 5 MG Oral Tablet [Qtern]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926069", "drug_name": "Ritonavir 100 MG Oral Powder [Norvir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926332", "drug_name": "0.5 UNT Doses 3 ML Insulin Lispro 100 UNT/ML Pen Injector [Humalog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926823", "drug_name": "C1 esterase inhibitor (human) 2000 UNT Injection [Haegarda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926827", "drug_name": "C1 esterase inhibitor (human) 3000 UNT Injection [Haegarda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926847", "drug_name": "Methylphenidate 17.3 MG Disintegrating Oral Tablet [Cotempla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926851", "drug_name": "Methylphenidate 25.9 MG Disintegrating Oral Tablet [Cotempla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1926855", "drug_name": "Methylphenidate 8.6 MG Disintegrating Oral Tablet [Cotempla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927366", "drug_name": "Aurovela 1/20 21 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927616", "drug_name": "3-Bead 24 HR Amphetamine aspartate 12.5 MG / Amphetamine Sulfate 12.5 MG / Dextroamphetamine saccharate 12.5 MG / Dextroamphetamine Sulfate 12.5 MG Extended Release Oral Capsule [Mydayis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927619", "drug_name": "3-Bead 24 HR Amphetamine aspartate 6.25 MG / Amphetamine Sulfate 6.25 MG / Dextroamphetamine saccharate 6.25 MG / Dextroamphetamine Sulfate 6.25 MG Extended Release Oral Capsule [Mydayis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927632", "drug_name": "3-Bead 24 HR Amphetamine aspartate 3.125 MG / Amphetamine Sulfate 3.125 MG / Dextroamphetamine saccharate 3.125 MG / Dextroamphetamine Sulfate 3.125 MG Extended Release Oral Capsule [Mydayis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927639", "drug_name": "3-Bead 24 HR Amphetamine aspartate 9.375 MG / Amphetamine Sulfate 9.375 MG / Dextroamphetamine saccharate 9.375 MG / Dextroamphetamine Sulfate 9.375 MG Extended Release Oral Capsule [Mydayis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927682", "drug_name": "delafloxacin 450 MG Oral Tablet [Baxdela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927693", "drug_name": "prasterone 6.5 MG Vaginal Insert [Intrarosa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927862", "drug_name": "betrixaban 40 MG Oral Capsule [Bevyxxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1927866", "drug_name": "betrixaban 80 MG Oral Capsule [Bevyxxa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1928689", "drug_name": "1 ML guselkumab 100 MG/ML Prefilled Syringe [Tremfya]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] }, { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1928941", "drug_name": "Glutamine 5000 MG Powder for Oral Solution [Endari]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1928954", "drug_name": "dronabinol 5 MG/ML Oral Solution [Syndros]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1928974", "drug_name": "influenza A virus A/Hong Kong/4801/2014 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Brisbane/60/2008 antigen 0.03 MG/ML Injectable Suspension [Fluvirin 2017-2018]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1928982", "drug_name": "0.5 ML influenza A virus A/Hong Kong/4801/2014 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Brisbane/60/2008 antigen 0.03 MG/ML Prefilled Syringe [Fluvirin 2017-2018]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1939299", "drug_name": "1 ML belimumab 200 MG/ML Auto-Injector [Benlysta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1939335", "drug_name": "sofosbuvir 400 MG / velpatasvir 100 MG / voxilaprevir 100 MG Oral Tablet [Vosevi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1939348", "drug_name": "1 ML belimumab 200 MG/ML Prefilled Syringe [Benlysta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1940372", "drug_name": "enasidenib 100 MG Oral Tablet [Idhifa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1940376", "drug_name": "enasidenib 50 MG Oral Tablet [Idhifa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1940498", "drug_name": "24 HR dapagliflozin 2.5 MG / Metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1940654", "drug_name": "neratinib 40 MG Oral Tablet [Nerlynx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1940709", "drug_name": "glecaprevir 100 MG / pibrentasvir 40 MG Oral Tablet [Mavyret]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941470", "drug_name": "nitisinone 10 MG Oral Tablet [Nityr]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941473", "drug_name": "nitisinone 5 MG Oral Tablet [Nityr]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941476", "drug_name": "nitisinone 2 MG Oral Tablet [Nityr]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941536", "drug_name": "60 ACTUAT Fluticasone propionate 0.113 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941607", "drug_name": "60 ACTUAT Fluticasone propionate 0.232 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1941613", "drug_name": "60 ACTUAT Fluticasone propionate 0.055 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1942485", "drug_name": "olaparib 100 MG Oral Tablet [Lynparza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1942489", "drug_name": "olaparib 150 MG Oral Tablet [Lynparza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1943345", "drug_name": "Spironolactone 5 MG/ML Oral Suspension [Carospir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944262", "drug_name": "Simvastatin 4 MG/ML Oral Suspension [Flolipid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944266", "drug_name": "Simvastatin 8 MG/ML Oral Suspension [Flolipid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944376", "drug_name": "24 HR Amantadine 137 MG Extended Release Oral Capsule [Gocovri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944382", "drug_name": "24 HR Amantadine 68.5 MG Extended Release Oral Capsule [Gocovri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944535", "drug_name": "Abuse-Deterrent Oxycodone Hydrochloride 15 MG Oral Tablet [Roxybond]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944540", "drug_name": "Abuse-Deterrent Oxycodone Hydrochloride 30 MG Oral Tablet [Roxybond]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944543", "drug_name": "Abuse-Deterrent Oxycodone Hydrochloride 5 MG Oral Tablet [Roxybond]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-SEVEN", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944785", "drug_name": "Allopurinol 300 MG / lesinurad 200 MG Oral Tablet [Duzallo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1944788", "drug_name": "Allopurinol 200 MG / lesinurad 200 MG Oral Tablet [Duzallo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1945044", "drug_name": "14 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1945048", "drug_name": "30 ACTUAT fluticasone furoate 0.1 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1945840", "drug_name": "Amphetamine 1.25 MG/ML Extended Release Suspension", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1945850", "drug_name": "Fenoprofen 600 MG Oral Tablet [Profeno]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946520", "drug_name": "3-Month 1.5 ML Leuprolide Acetate 20 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946522", "drug_name": "4-Month 1.5 ML Leuprolide Acetate 20 MG/ML Prefilled Syringe [Lupron]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946525", "drug_name": "Matrix Delivery 24 HR tramadol hydrochloride 300 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946527", "drug_name": "Matrix Delivery 24 HR tramadol hydrochloride 200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946529", "drug_name": "Matrix Delivery 24 HR tramadol hydrochloride 100 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946589", "drug_name": "Fluticasone propionate 0.093 MG/ACTUAT Metered Dose Nasal Spray [Xhance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946698", "drug_name": "secnidazole 2000 MG Oral Granules [Solosec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946784", "drug_name": "Guaifenesin 388 MG / Phenylephrine Hydrochloride 10 MG Oral Tablet [Gilphex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946836", "drug_name": "abemaciclib 50 MG Oral Tablet [Verzenio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946840", "drug_name": "abemaciclib 100 MG Oral Tablet [Verzenio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946844", "drug_name": "abemaciclib 150 MG Oral Tablet [Verzenio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1946848", "drug_name": "abemaciclib 200 MG Oral Tablet [Verzenio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1947382", "drug_name": "fibrinogen concentrate (human) 1 MG Injection [Fibryga]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986331", "drug_name": "valbenazine 80 MG Oral Capsule [Ingrezza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986354", "drug_name": "insulin aspart, human 100 UNT/ML Injectable Solution [Fiasp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986356", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Pen Injector [Fiasp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986791", "drug_name": "Aurovela Fe 1.5/30 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986819", "drug_name": "acalabrutinib 100 MG Oral Capsule [Calquence]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1986830", "drug_name": "0.5 ML Varicella zoster virus glycoprotein E, recombinant 0.1 MG/ML Injection [Shingrix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1987646", "drug_name": "Tretinoin 0.0006 MG/MG Topical Gel [Retin-A]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1987734", "drug_name": "bosutinib 400 MG Oral Tablet [Bosulif]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988308", "drug_name": "24 HR Diltiazem Hydrochloride 120 MG Extended Release Oral Capsule [Tiadylt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988311", "drug_name": "24 HR Diltiazem Hydrochloride 180 MG Extended Release Oral Capsule [Tiadylt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988316", "drug_name": "24 HR Diltiazem Hydrochloride 240 MG Extended Release Oral Capsule [Tiadylt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988319", "drug_name": "24 HR Diltiazem Hydrochloride 300 MG Extended Release Oral Capsule [Tiadylt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988330", "drug_name": "24 HR Diltiazem Hydrochloride 420 MG Extended Release Oral Capsule [Tiadylt]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988399", "drug_name": "Latanoprostene Bunod 0.24 MG/ML Ophthalmic Solution [Vyzulta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988657", "drug_name": "12 ML letermovir 20 MG/ML Injection [Prevymis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988661", "drug_name": "24 ML letermovir 20 MG/ML Injection [Prevymis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988671", "drug_name": "letermovir 240 MG Oral Tablet [Prevymis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988675", "drug_name": "letermovir 480 MG Oral Tablet [Prevymis]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1988786", "drug_name": "Alunbrig Initiation Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989085", "drug_name": "bosentan 32 MG Tablet for Oral Suspension [Tracleer]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989117", "drug_name": "0.3 ML Epinephrine 1 MG/ML Prefilled Syringe [Symjepi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989506", "drug_name": "dolutegravir 50 MG / Rilpivirine 25 MG Oral Tablet [Juluca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989507", "drug_name": "Hailey 24 Fe 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989804", "drug_name": "1 ML emicizumab-kxwh 30 MG/ML Injection [Hemlibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989811", "drug_name": "0.7 ML emicizumab-kxwh 150 MG/ML Injection [Hemlibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989815", "drug_name": "0.4 ML emicizumab-kxwh 150 MG/ML Injection [Hemlibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1989817", "drug_name": "1 ML emicizumab-kxwh 150 MG/ML Injection [Hemlibra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1990745", "drug_name": "Methadone Hydrochloride 40 MG Tablet for Oral Suspension [Diskets]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1990862", "drug_name": "coagulation factor IX (recombinant), glycopegylated 1 UNT Injection [Rebinyn]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1990869", "drug_name": "0.85 ML exenatide 2.35 MG/ML Auto-Injector [Bydureon]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1991311", "drug_name": "0.25 MG, 0.5 MG Dose 1.5 ML semaglutide 1.34 MG/ML Pen Injector [Ozempic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1991317", "drug_name": "1 MG Dose 1.5 ML semaglutide 1.34 MG/ML Pen Injector [Ozempic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1991329", "drug_name": "NDA201739 0.1 ML Epinephrine 1 MG/ML Auto-Injector [Auvi-Q]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1991411", "drug_name": "Desmopressin Acetate 0.00166 MG/ACTUAT Metered Dose Nasal Spray [Noctiva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1991509", "drug_name": "Citric Acid 75 MG/ML / Magnesium Oxide 21.9 MG/ML / picosulfate sodium 0.0625 MG/ML Oral Solution [Clenpiq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992169", "drug_name": "Insulin Lispro 100 UNT/ML Injectable Solution [Admelog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992171", "drug_name": "3 ML Insulin Lispro 100 UNT/ML Pen Injector [Admelog]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992273", "drug_name": "Emollient Clobetasol Propionate 0.5 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992274", "drug_name": "Emollient Clobetasol Propionate 0.5 MG/ML Topical Foam [Olux]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992281", "drug_name": "Emollient Clobetasol Propionate 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992299", "drug_name": "24 HR Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992300", "drug_name": "24 HR Timolol 5 MG/ML Ophthalmic Solution [Istalol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992303", "drug_name": "12 HR Timolol 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992304", "drug_name": "12 HR Timolol 5 MG/ML Ophthalmic Solution [Timoptic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992305", "drug_name": "12 HR Timolol 5 MG/ML Ophthalmic Solution [Betimol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992428", "drug_name": "Eliquis 30-Day Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992571", "drug_name": "Glycopyrrolate 0.025 MG/ML Inhalation Solution [Lonhala]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992691", "drug_name": "ertugliflozin 2.5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Segluromet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992695", "drug_name": "ertugliflozin 2.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Segluromet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992700", "drug_name": "ertugliflozin 7.5 MG / Metformin hydrochloride 1000 MG Oral Tablet [Segluromet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992703", "drug_name": "ertugliflozin 7.5 MG / Metformin hydrochloride 500 MG Oral Tablet [Segluromet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992816", "drug_name": "ertugliflozin 5 MG Oral Tablet [Steglatro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992821", "drug_name": "ertugliflozin 15 MG Oral Tablet [Steglatro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992832", "drug_name": "ertugliflozin 15 MG / sitagliptin 100 MG Oral Tablet [Steglujan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992837", "drug_name": "ertugliflozin 5 MG / sitagliptin 100 MG Oral Tablet [Steglujan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1992873", "drug_name": "netarsudil 0.2 MG/ML Ophthalmic Solution [Rhopressa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1993222", "drug_name": "benznidazole 12.5 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994352", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.04 MG/ML Injection [Heplisav-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994362", "drug_name": "Ibrutinib 70 MG Oral Capsule [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994389", "drug_name": "24 HR pregabalin 165 MG Extended Release Oral Tablet [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994392", "drug_name": "24 HR pregabalin 330 MG Extended Release Oral Tablet [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994395", "drug_name": "24 HR pregabalin 82.5 MG Extended Release Oral Tablet [Lyrica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1994750", "drug_name": "ozenoxacin 10 MG/ML Topical Cream [Xepi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1995460", "drug_name": "Clobetasol Propionate 0.25 MG/ML Topical Cream [Impoyz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1995479", "drug_name": "amylase 168000 UNT / lipase 40000 UNT / protease 126000 UNT Delayed Release Oral Capsule [Zenpep]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1995536", "drug_name": "Acetaminophen 325 MG / Caffeine 30 MG / dihydrocodeine bitartrate 16 MG Oral Tablet [Panlor Reformulated Jan 2018]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1998475", "drug_name": "Flurandrenolide 0.5 MG/ML Topical Cream [Nolix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1998631", "drug_name": "American house dust mite allergenic extract 6 SQ-HDM / European house dust mite allergenic extract 6 SQ-HDM Sublingual Tablet [Odactra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1998772", "drug_name": "Breath-Actuated 120 ACTUAT Beclomethasone Dipropionate 0.08 MG/ACTUAT Metered Dose Inhaler [Qvar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1998774", "drug_name": "Breath-Actuated 120 ACTUAT Beclomethasone Dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler [Qvar]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999026", "drug_name": "Balcoltra 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999314", "drug_name": "hydroxyurea 100 MG Oral Tablet [Siklos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999389", "drug_name": "symdeko 100 MG / 150 MG and 150 MG Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999587", "drug_name": "apalutamide 60 MG Oral Tablet [Erleada]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999657", "drug_name": "12 HR doxylamine succinate 20 MG / Pyridoxine Hydrochloride 20 MG Extended Release Oral Tablet [Bonjesta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999673", "drug_name": "bictegravir 50 MG / emtricitabine 200 MG / tenofovir alafenamide 25 MG Oral Tablet [Biktarvy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "1999724", "drug_name": "Tydemy 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000007", "drug_name": "1 ML glatiramer acetate 40 MG/ML Prefilled Syringe [Glatopa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000019", "drug_name": "Ibrutinib 140 MG Oral Tablet [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000023", "drug_name": "Ibrutinib 280 MG Oral Tablet [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000027", "drug_name": "Ibrutinib 420 MG Oral Tablet [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000031", "drug_name": "Ibrutinib 560 MG Oral Tablet [Imbruvica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000133", "drug_name": "Vancomycin 25 MG/ML Oral Solution [Firvanq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000134", "drug_name": "Vancomycin 50 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2000136", "drug_name": "Vancomycin 50 MG/ML Oral Solution [Firvanq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001260", "drug_name": "pitavastatin magnesium 1 MG Oral Tablet [Zypitamag]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001264", "drug_name": "pitavastatin magnesium 2 MG Oral Tablet [Zypitamag]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001268", "drug_name": "pitavastatin magnesium 4 MG Oral Tablet [Zypitamag]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001321", "drug_name": "Roflumilast 0.25 MG Oral Tablet [Daliresp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001358", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 6.12 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001364", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 6.12 MG Oral Tablet [Apadaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001424", "drug_name": "efavirenz 400 MG / Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001430", "drug_name": "efavirenz 400 MG / Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Symfi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001439", "drug_name": "Lidocaine 0.018 MG/MG Medicated Patch [ZTlido]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001564", "drug_name": "BX Rating 24 HR Methylphenidate Hydrochloride 18 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001565", "drug_name": "BX Rating 24 HR Methylphenidate Hydrochloride 27 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001566", "drug_name": "BX Rating 24 HR Methylphenidate Hydrochloride 36 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2001568", "drug_name": "BX Rating 24 HR Methylphenidate Hydrochloride 54 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2002420", "drug_name": "3 ML Insulin Glargine 300 UNT/ML Pen Injector [Toujeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2002719", "drug_name": "nilotinib 50 MG Oral Capsule [Tasigna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2003255", "drug_name": "Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Cimduo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2003714", "drug_name": "1 ML Morphine Sulfate 2 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2003757", "drug_name": "1.14 ML sarilumab 132 MG/ML Auto-Injector [Kevzara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2003767", "drug_name": "1.14 ML sarilumab 175 MG/ML Auto-Injector [Kevzara]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2043464", "drug_name": "efavirenz 600 MG / Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Symfi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044355", "drug_name": "tolvaptan 15 MG Oral Tablet [Jynarque]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044357", "drug_name": "tolvaptan 30 MG Oral Tablet [Jynarque]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044720", "drug_name": "24 HR Amantadine 129 MG Extended Release Oral Tablet [Osmolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044726", "drug_name": "24 HR Amantadine 193 MG Extended Release Oral Tablet [Osmolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044732", "drug_name": "24 HR Amantadine 258 MG Extended Release Oral Tablet [Osmolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044928", "drug_name": "fostamatinib 100 MG Oral Tablet [Tavalisse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044932", "drug_name": "fostamatinib 150 MG Oral Tablet [Tavalisse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044967", "drug_name": "Jynarque 60 MG / 30 MG Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044969", "drug_name": "Jynarque 45 MG / 15 MG Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2044971", "drug_name": "Jynarque 90 MG / 30 MG Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045245", "drug_name": "Plenvu Kit {1 (POLYETHYLENE GLYCOL 3350 100 GM / Potassium Chloride 1 GM / Sodium Chloride 2 GM / sodium sulfate 9 GM Powder for Oral Solution) / 1 (ascorbic acid 7.54 GM / POLYETHYLENE GLYCOL 3350 40 GM / Potassium Chloride 1.2 GM / sodium ascorbate 48.11 GM / Sodium Chloride 3.2 GM Powder for Oral Solution) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045382", "drug_name": "30 ACTUAT fluticasone furoate 0.05 MG/ACTUAT Dry Powder Inhaler [Arnuity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045638", "drug_name": "1 ML erenumab-aooe 70 MG/ML Auto-Injector [Aimovig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045958", "drug_name": "avatrombopag 20 MG Oral Tablet [Doptelet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045959", "drug_name": "Doptelet 40 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2045961", "drug_name": "Doptelet 60 MG Daily Dose Carton Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2046370", "drug_name": "0.5 ML pegvaliase-pqpz 20 MG/ML Prefilled Syringe [Palynziq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2046376", "drug_name": "0.5 ML pegvaliase-pqpz 5 MG/ML Prefilled Syringe [Palynziq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2046380", "drug_name": "1 ML pegvaliase-pqpz 20 MG/ML Prefilled Syringe [Palynziq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2046585", "drug_name": "abiraterone acetate 125 MG Oral Tablet [Yonsa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2046597", "drug_name": "lofexidine 0.18 MG Oral Tablet [Lucemyra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047247", "drug_name": "baricitinib 2 MG Oral Tablet [Olumiant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047596", "drug_name": "1 ML epoetin alfa-epbx 10000 UNT/ML Injection [Retacrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047602", "drug_name": "1 ML epoetin alfa-epbx 2000 UNT/ML Injection [Retacrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047608", "drug_name": "1 ML epoetin alfa-epbx 3000 UNT/ML Injection [Retacrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047614", "drug_name": "1 ML epoetin alfa-epbx 4000 UNT/ML Injection [Retacrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047623", "drug_name": "1 ML epoetin alfa-epbx 40000 UNT/ML Injection [Retacrit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047639", "drug_name": "sodium zirconium cyclosilicate 5000 MG Powder for Oral Suspension [Lokelma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047646", "drug_name": "halobetasol propionate 0.5 MG/ML Topical Foam", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047766", "drug_name": "24 HR metoprolol succinate 100 MG Extended Release Oral Capsule [Kapspargo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047769", "drug_name": "24 HR metoprolol succinate 200 MG Extended Release Oral Capsule [Kapspargo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047772", "drug_name": "24 HR metoprolol succinate 25 MG Extended Release Oral Capsule [Kapspargo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047775", "drug_name": "24 HR metoprolol succinate 50 MG Extended Release Oral Capsule [Kapspargo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2047882", "drug_name": "1 ML testosterone cypionate 200 MG/ML Injection", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2048017", "drug_name": "Atropine Sulfate 0.00388 MG/ML / Hyoscyamine Sulfate 0.0207 MG/ML / Phenobarbital 3.24 MG/ML / Scopolamine Hydrobromide 0.0013 MG/ML Oral Solution [Phenohytro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2048025", "drug_name": "0.6 ML pegfilgrastim-jmdb 10 MG/ML Prefilled Syringe [Fulphila]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2048568", "drug_name": "tofacitinib 10 MG Oral Tablet [Xeljanz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2048966", "drug_name": "0.5 ML influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Fluarix Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049117", "drug_name": "encorafenib 50 MG Oral Capsule [Braftovi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049121", "drug_name": "encorafenib 75 MG Oral Capsule [Braftovi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049271", "drug_name": "pimavanserin 10 MG Oral Tablet [Nuplazid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049278", "drug_name": "pimavanserin 34 MG Oral Capsule [Nuplazid]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049380", "drug_name": "3 ML insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Pen Injector [Novolin]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049593", "drug_name": "Amlodipine 2.5 MG / celecoxib 200 MG Oral Tablet [Consensi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049603", "drug_name": "crotamiton 100 MG/ML Topical Lotion [Crotan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049677", "drug_name": "cobicistat 150 MG / darunavir 800 MG / emtricitabine 200 MG / tenofovir alafenamide 10 MG Oral Tablet [Symtuza]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049858", "drug_name": "elagolix 150 MG Oral Tablet [Orilissa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049862", "drug_name": "elagolix 200 MG Oral Tablet [Orilissa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2049884", "drug_name": "ivosidenib 250 MG Oral Tablet [Tibsovo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050059", "drug_name": "0.5 ML Hepatitis B Surface Antigen Vaccine 0.04 MG/ML Prefilled Syringe [Heplisav-B]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050423", "drug_name": "0.5 ML influenza A virus A/Michigan/45/2015 (H1N1) antigen 0.12 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.12 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.12 MG/ML Prefilled Syringe [Fluzone 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050771", "drug_name": "influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML Injectable Suspension [Afluria 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050782", "drug_name": "0.5 ML influenza A virus A/Michigan/45/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injection [Fluzone Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050787", "drug_name": "influenza A virus A/Michigan/45/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injectable Suspension [Fluzone Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050789", "drug_name": "0.25 ML influenza A virus A/Michigan/45/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Fluzone Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050795", "drug_name": "influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injectable Suspension [Afluria Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050797", "drug_name": "0.5 ML influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Afluria Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2050803", "drug_name": "0.5 ML influenza A virus A/Singapore/GP1908/2015 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML Prefilled Syringe [Afluria 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2052609", "drug_name": "Tacrolimus 0.2 MG Granules for Oral Suspension [Prograf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2052704", "drug_name": "Tacrolimus 1 MG Granules for Oral Suspension [Prograf]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2053512", "drug_name": "ivacaftor 125 MG / lumacaftor 100 MG Oral Granules [ORKAMBI]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2053519", "drug_name": "ivacaftor 188 MG / lumacaftor 150 MG Oral Granules [ORKAMBI]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2053927", "drug_name": "sodium zirconium cyclosilicate 10000 MG Powder for Oral Suspension [Lokelma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054102", "drug_name": "tafenoquine 100 MG Oral Tablet [Arakoda]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054269", "drug_name": "INGREZZA 40 MG / 80 MG Starter Pack, 28 capsules", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054274", "drug_name": "influenza A virus A/Singapore/INFIMH-16-0019/2016 (H3N2) antigen 158000000 UNT/ML / influenza A virus A/Slovenia/2903/2015 (H1N1) antigen 158000000 UNT/ML / influenza B virus B/Colorado/06/2017 antigen 158000000 UNT/ML / influenza B virus B/Phuket/3073/2013 antigen 158000000 UNT/ML Nasal Spray [Flumist Quadrivalent 2018-2019]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054275", "drug_name": "Galafold 123 MG 28 Day (4 Week) Wallet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054979", "drug_name": "stiripentol 250 MG Oral Capsule [Diacomit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054983", "drug_name": "stiripentol 500 MG Oral Capsule [Diacomit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2054995", "drug_name": "lusutrombopag 3 MG Oral Tablet [Mulpleta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055008", "drug_name": "Tretinoin 0.5 MG/ML Topical Lotion [Altreno]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055014", "drug_name": "stiripentol 500 MG Powder for Oral Suspension [Diacomit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055016", "drug_name": "stiripentol 250 MG Powder for Oral Suspension [Diacomit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055026", "drug_name": "Cyclosporine 0.9 MG/ML Ophthalmic Solution [Cequa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055286", "drug_name": "loteprednol etabonate 10 MG/ML Ophthalmic Suspension [Inveltys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055650", "drug_name": "2 ML lanadelumab-flyo 150 MG/ML Injection [Takhzyro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055664", "drug_name": "antihemophilic factor (recombinant), PEGylated-aucl 1 UNT Injection [Jivi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055766", "drug_name": "DORAVIRINE 100 MG Oral Tablet [Pifeltro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055815", "drug_name": "DORAVIRINE 100 MG / Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Delstrigo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2055989", "drug_name": "273 DAY Ethinyl Estradiol 0.000542 MG/HR / segesterone acetate 0.00625 MG/HR Vaginal System [Annovera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056466", "drug_name": "Levothyroxine Sodium 0.025 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056470", "drug_name": "Levothyroxine Sodium 0.05 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056474", "drug_name": "Levothyroxine Sodium 0.075 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056478", "drug_name": "Levothyroxine Sodium 0.088 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056482", "drug_name": "Levothyroxine Sodium 0.1 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056486", "drug_name": "Levothyroxine Sodium 0.112 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056490", "drug_name": "Levothyroxine Sodium 0.125 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056494", "drug_name": "Levothyroxine Sodium 0.013 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056498", "drug_name": "Levothyroxine Sodium 0.137 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056502", "drug_name": "Levothyroxine Sodium 0.15 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056506", "drug_name": "Levothyroxine Sodium 0.175 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056510", "drug_name": "Levothyroxine Sodium 0.2 MG/ML Oral Solution [Tirosint]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056670", "drug_name": "Aimovig Autoinjector 2-Pack (140 MG Dose)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056700", "drug_name": "1.5 ML fremanezumab-vfrm 150 MG/ML Prefilled Syringe [Ajovy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056748", "drug_name": "latanoprost 0.05 MG/ML Ophthalmic Suspension [Xelpros]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2056897", "drug_name": "everolimus 1 MG Oral Tablet [Zortress]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2057205", "drug_name": "0.5 ML filgrastim-aafi 0.6 MG/ML Prefilled Syringe [Nivestym]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2057216", "drug_name": "0.8 ML filgrastim-aafi 0.6 MG/ML Prefilled Syringe [Nivestym]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058520", "drug_name": "Duvelisib 15 MG Oral Capsule [Copiktra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058525", "drug_name": "Duvelisib 25 MG Oral Capsule [Copiktra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058877", "drug_name": "1 ML galcanezumab-gnlm 120 MG/ML Auto-Injector [Emgality]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058906", "drug_name": "cannabidiol 100 MG/ML Oral Solution [Epidiolex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058922", "drug_name": "dacomitinib 15 MG Oral Tablet [Vizimpro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058926", "drug_name": "dacomitinib 30 MG Oral Tablet [Vizimpro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058932", "drug_name": "dacomitinib 45 MG Oral Tablet [Vizimpro]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2058981", "drug_name": "eltrombopag 12.5 MG Powder for Oral Suspension [Promacta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2059017", "drug_name": "rivaroxaban 2.5 MG Oral Tablet [Xarelto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2059189", "drug_name": "amikacin liposomal 70.3 MG/ML Inhalation Suspension [Arikayce]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2059266", "drug_name": "Riluzole 5 MG/ML Oral Suspension [Tiglutik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2059280", "drug_name": "omadacycline 150 MG Oral Tablet [Nuzyra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099132", "drug_name": "Benoxinate hydrochloride 4 MG/ML / fluorescein sodium 2.5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099302", "drug_name": "1.14 ML dupilumab 175 MG/ML Prefilled Syringe [Dupixent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099323", "drug_name": "1.5 ML inotersen 189 MG/ML Prefilled Syringe [Tegsedi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099508", "drug_name": "Hailey Fe 1.5/30 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099522", "drug_name": "Benoxinate hydrochloride 4 MG/ML / fluorescein sodium 2.5 MG/ML Ophthalmic Solution [Altafluor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099528", "drug_name": "Benoxinate hydrochloride 4 MG/ML / fluorescein sodium 2.5 MG/ML Ophthalmic Solution [Flurox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099686", "drug_name": "0.5 ML testosterone enanthate 200 MG/ML Auto-Injector [Xyosted]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099691", "drug_name": "0.5 ML testosterone enanthate 100 MG/ML Auto-Injector [Xyosted]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099697", "drug_name": "0.5 ML testosterone enanthate 150 MG/ML Auto-Injector [Xyosted]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099700", "drug_name": "1 ML Dexamethasone phosphate 10 MG/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099952", "drug_name": "talazoparib 0.25 MG Oral Capsule [Talzenna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2099956", "drug_name": "talazoparib 1 MG Oral Capsule [Talzenna]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2100099", "drug_name": "Xofluza 40 MG Dose Pack (2 x 20 MG Tablets)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2100100", "drug_name": "Xofluza 80 MG Dose Pack (2 x 40 MG Tablets)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2101459", "drug_name": "1 ML Tbo-filgrastim 0.3 MG/ML Injection [Granix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2101465", "drug_name": "1.6 ML Tbo-filgrastim 0.3 MG/ML Injection [Granix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2101715", "drug_name": "halobetasol propionate 0.1 MG/ML Topical Lotion [Bryhali]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102705", "drug_name": "0.6 ML pegfilgrastim-cbqv 10 MG/ML Prefilled Syringe [Udenyca]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102713", "drug_name": "clobazam 10 MG Oral Film [Sympazan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102715", "drug_name": "clobazam 20 MG Oral Film [Sympazan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102717", "drug_name": "clobazam 5 MG Oral Film [Sympazan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102784", "drug_name": "Revefenacin 0.0583 MG/ML Inhalation Solution [Yupelri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2102949", "drug_name": "Prochlorperazine 5 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2103018", "drug_name": "Penicillamine 125 MG Oral Tablet [D-Penamine]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2103175", "drug_name": "Lorlatinib 25 MG Oral Tablet [Lorbrena]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2103179", "drug_name": "Lorlatinib 100 MG Oral Tablet [Lorbrena]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2104192", "drug_name": "Tri-VyLibra Lo 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2104341", "drug_name": "cenegermin-bkbj 0.02 MG/ML Ophthalmic Solution [Oxervate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2104866", "drug_name": "Levothyroxine Sodium 0.137 MG Oral Tablet [Euthyrox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105645", "drug_name": "larotrectinib 100 MG Oral Capsule [Vitrakvi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105653", "drug_name": "larotrectinib 20 MG/ML Oral Solution [Vitrakvi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105657", "drug_name": "larotrectinib 25 MG Oral Capsule [Vitrakvi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105817", "drug_name": "gilteritinib 40 MG Oral Tablet [Xospata]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105856", "drug_name": "glasdegib 100 MG Oral Tablet [Daurismo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2105860", "drug_name": "glasdegib 25 MG Oral Tablet [Daurismo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2106075", "drug_name": "0.9 ML tocilizumab 180 MG/ML Auto-Injector [Actemra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2106362", "drug_name": "rifamycin SV 194 MG Delayed Release Oral Tablet [Aemcolo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2106585", "drug_name": "halobetasol propionate 0.5 MG/ML Topical Foam [Lexette]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2106648", "drug_name": "Itraconazole 65 MG Oral Capsule [Tolsura]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107008", "drug_name": "Tarina 24 FE 1/20 28 Day", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107351", "drug_name": "prucalopride 1 MG Oral Tablet [Motegrity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107355", "drug_name": "prucalopride 2 MG Oral Tablet [Motegrity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107518", "drug_name": "amifampridine 10 MG Oral Tablet [Firdapse]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107522", "drug_name": "insulin degludec 100 UNT/ML Injectable Solution [Tresiba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2107621", "drug_name": "Levodopa 42 MG Inhalation Powder [Inbrija]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2108930", "drug_name": "Estradiol 1 MG / Progesterone 100 MG Oral Capsule [Bijuva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2109239", "drug_name": "tafenoquine 150 MG Oral Tablet [Krintafel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2110455", "drug_name": "Pulmonary Hypertension tadalafil 20 MG Oral Tablet [Alyq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2110510", "drug_name": "60 ACTUAT Fluticasone propionate 0.1 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Wixela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2110513", "drug_name": "60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Wixela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2110516", "drug_name": "60 ACTUAT Fluticasone propionate 0.5 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Wixela]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2110618", "drug_name": "caplacizumab-yhdp 11 MG Injection [Cablivi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118539", "drug_name": "loteprednol etabonate 0.0038 MG/MG Ophthalmic Gel [Lotemax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118588", "drug_name": "meloxicam 15 MG Disintegrating Oral Tablet [Qmiiz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118591", "drug_name": "meloxicam 7.5 MG Disintegrating Oral Tablet [Qmiiz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118728", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 4.08 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118730", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 4.08 MG Oral Tablet [Apadaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118732", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 8.16 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118734", "drug_name": "Acetaminophen 325 MG / benzhydrocodone 8.16 MG Oral Tablet [Apadaz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2118741", "drug_name": "1 ML guselkumab 100 MG/ML Auto-Injector [Tremfya]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119481", "drug_name": "Cetirizine 2.4 MG/ML Ophthalmic Solution [Zerviate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119561", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 25 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119565", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 35 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119569", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 45 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119573", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 55 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119575", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 85 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119579", "drug_name": "20/80 Release 24 HR Methylphenidate Hydrochloride 70 MG Extended Release Oral Capsule [Adhansia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2119706", "drug_name": "latanoprost 0.05 MG/ML / netarsudil 0.2 MG/ML Ophthalmic Solution [Rocklatan]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2120195", "drug_name": "1 ML erenumab-aooe 140 MG/ML Auto-Injector [Aimovig]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121061", "drug_name": "ceritinib 150 MG Oral Tablet [Zykadia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121096", "drug_name": "siponimod 0.25 MG Oral Tablet [Mayzent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121100", "drug_name": "siponimod 2 MG Oral Tablet [Mayzent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121591", "drug_name": "0.5 ML heparin sodium, porcine 10000 UNT/ML Prefilled Syringe", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121735", "drug_name": "Dxevo 11 Day Taper Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121764", "drug_name": "Solriamfetol 75 MG Oral Tablet [Sunosi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2121776", "drug_name": "testosterone undecanoate 237 MG Oral Capsule [Jatenzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122343", "drug_name": "doxycycline hyclate 80 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122526", "drug_name": "dolutegravir 50 MG / Lamivudine 300 MG Oral Tablet [Dovato]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122642", "drug_name": "Mavenclad 9 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122648", "drug_name": "Mavenclad 8 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122650", "drug_name": "Mavenclad 7 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122655", "drug_name": "Mavenclad 6 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122657", "drug_name": "Mavenclad 5 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122659", "drug_name": "Mavenclad 4 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2122661", "drug_name": "Mavenclad 10 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123034", "drug_name": "Lamivudine 300 MG / Tenofovir disoproxil fumarate 300 MG Oral Tablet [Temixys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123042", "drug_name": "50 ML immune globulin intravenous (human) - slra 100 MG/ML Injection [Asceniv]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123072", "drug_name": "NDA021457 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123076", "drug_name": "NDA020983 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123111", "drug_name": "NDA020503 200 ACTUAT Albuterol 0.09 MG/ACTUAT Metered Dose Inhaler", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123137", "drug_name": "erdafitinib 3 MG Oral Tablet [Balversa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123141", "drug_name": "erdafitinib 4 MG Oral Tablet [Balversa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123145", "drug_name": "erdafitinib 5 MG Oral Tablet [Balversa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123190", "drug_name": "1.17 ML romosozumab-aqqg 89.7 MG/ML Prefilled Syringe [Evenity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2123191", "drug_name": "Evenity 210 MG Dose Pack (2 count)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166094", "drug_name": "halobetasol propionate 0.1 MG/ML / tazarotene 0.45 MG/ML Topical Lotion [Duobrii]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166143", "drug_name": "Skyrizi 75 MG/83 ML X 2 (150 MG) Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166204", "drug_name": "10 ACTUAT tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Spiriva]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166401", "drug_name": "ivacaftor 25 MG Oral Granules [Kalydeco]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166797", "drug_name": "Sensor 200 ACTUAT Albuterol 0.09 MG/ACTUAT Dry Powder Inhaler [ProAir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2166928", "drug_name": "10 ACTUAT olodaterol 0.0025 MG/ACTUAT / tiotropium 0.0025 MG/ACTUAT Inhalation Spray [Stiolto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2167563", "drug_name": "rosuvastatin 10 MG Oral Capsule [Ezallor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2167567", "drug_name": "rosuvastatin 20 MG Oral Capsule [Ezallor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2167571", "drug_name": "rosuvastatin 40 MG Oral Capsule [Ezallor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2167575", "drug_name": "rosuvastatin 5 MG Oral Capsule [Ezallor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168540", "drug_name": "tafamidis 61 MG Oral Capsule [Vyndamax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168548", "drug_name": "Tafamidis meglumine 20 MG Oral Capsule [Vyndaqel]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168596", "drug_name": "ivabradine 1 MG/ML Oral Solution [Corlanor]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168765", "drug_name": "tesamorelin 1 MG Injection [Egrifta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168859", "drug_name": "Evening Dosing 24 HR Methylphenidate Hydrochloride 60 MG Extended Release Oral Capsule [Jornay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168863", "drug_name": "Evening Dosing 24 HR Methylphenidate Hydrochloride 80 MG Extended Release Oral Capsule [Jornay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168865", "drug_name": "Evening Dosing 24 HR Methylphenidate Hydrochloride 100 MG Extended Release Oral Capsule [Jornay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168867", "drug_name": "Evening Dosing 24 HR Methylphenidate Hydrochloride 20 MG Extended Release Oral Capsule [Jornay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2168869", "drug_name": "Evening Dosing 24 HR Methylphenidate Hydrochloride 40 MG Extended Release Oral Capsule [Jornay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2169276", "drug_name": "dapagliflozin 5 MG / saxagliptin 5 MG Oral Tablet [Qtern]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2169314", "drug_name": "Piqray 200 MG Daily Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2169320", "drug_name": "Piqray 250 MG Daily Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2169322", "drug_name": "Piqray 300 MG Daily Dose Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2170613", "drug_name": "1 ML galcanezumab-gnlm 100 MG/ML Prefilled Syringe [Emgality]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2170993", "drug_name": "1 ML mepolizumab 100 MG/ML Auto-Injector [Nucala]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2171002", "drug_name": "Slynd 28 Day Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2173500", "drug_name": "Midazolam 50 MG/ML Nasal Spray [Nayzilam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2173822", "drug_name": "1 ML mepolizumab 100 MG/ML Prefilled Syringe [Nucala]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2173841", "drug_name": "Solriamfetol 150 MG Oral Tablet [Sunosi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2174390", "drug_name": "symdeko 50 MG / 75 MG and 75 MG Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2174818", "drug_name": "amifampridine 10 MG Oral Tablet [Ruzurgi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2175796", "drug_name": "Amphetamine Sulfate 10 MG Disintegrating Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2175891", "drug_name": "Amphetamine Sulfate 15 MG Disintegrating Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2175893", "drug_name": "Amphetamine Sulfate 20 MG Disintegrating Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2175894", "drug_name": "Amphetamine Sulfate 5 MG Disintegrating Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2176321", "drug_name": "0.3 ML bremelanotide 5.83 MG/ML Auto-Injector [Vyleesi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177398", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Fluarix Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177495", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Fluzone Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177500", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injection [Fluzone Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177504", "drug_name": "0.25 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Fluzone Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177592", "drug_name": "influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injectable Suspension [Fluzone Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177697", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.12 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.12 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.12 MG/ML Prefilled Syringe [Fluzone 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177794", "drug_name": "influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injectable Suspension [Flulaval Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2177797", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Flulaval Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178073", "drug_name": "Sumatriptan 10 MG/ACTUAT Nasal Spray [Tosymra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178077", "drug_name": "tiopronin 100 MG Delayed Release Oral Tablet [Thiola]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178081", "drug_name": "tiopronin 300 MG Delayed Release Oral Tablet [Thiola]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178362", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML Prefilled Syringe [Fluad 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178403", "drug_name": "Xpovio 60 MG Weekly Dose Carton Pack, 4 Blister Cards, 3 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178405", "drug_name": "Xpovio 80 MG Weekly Dose Carton Pack, 4 Blister Cards, 4 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178407", "drug_name": "Xpovio 80 MG Twice Weekly (160 MG total weekly) Dose Carton Pack, 4 Blister Cards, 8 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178409", "drug_name": "Xpovio 100 MG Weekly Dose Carton Pack, 4 Blister Cards, 5 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178785", "drug_name": "0.5 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Afluria Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178787", "drug_name": "0.25 ML influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Prefilled Syringe [Afluria Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178789", "drug_name": "influenza A virus A/Brisbane/02/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Kansas/14/2017 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Maryland/15/2016 antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML Injectable Suspension [Afluria Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2178792", "drug_name": "0.3 ML Epinephrine 0.5 MG/ML Prefilled Syringe [Symjepi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2179635", "drug_name": "tramadol hydrochloride 100 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2179758", "drug_name": "trastuzumab-dkst 150 MG Injection [Ogivri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2179763", "drug_name": "trastuzumab-dkst 21 MG/ML Injectable Solution [Ogivri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180336", "drug_name": "darolutamide 300 MG Oral Tablet [Nubeqa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180350", "drug_name": "Benzoyl Peroxide 98 MG/ML Topical Foam [Enzoclear]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180406", "drug_name": "0.5 ML influenza A virus A/Idaho/07/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Indiana/08/2018 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Iowa/06/2017 antigen 0.03 MG/ML / influenza B virus B/Singapore/INFTT-16-0610/2016 antigen 0.03 MG/ML Prefilled Syringe [Flucelvax Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180411", "drug_name": "influenza A virus A/Idaho/07/2018 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Indiana/08/2018 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Iowa/06/2017 antigen 0.03 MG/ML / influenza B virus B/Singapore/INFTT-16-0610/2016 antigen 0.03 MG/ML Injectable Suspension [Flucelvax Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180558", "drug_name": "Colchicine 0.12 MG/ML Oral Solution [Gloperba]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180671", "drug_name": "Glucagon 3 MG Nasal Powder [Baqsimi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2180999", "drug_name": "deferiprone 1000 MG Oral Tablet [Ferriprox]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2183131", "drug_name": "pexidartinib 200 MG Oral Capsule [Turalio]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2183907", "drug_name": "Dexchlorpheniramine maleate 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2184126", "drug_name": "Amlodipine 1 MG/ML Oral Suspension [Katerzia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2196592", "drug_name": "120 ACTUAT formoterol fumarate 0.005 MG/ACTUAT / mometasone furoate 0.05 MG/ACTUAT Metered Dose Inhaler [Dulera]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2196792", "drug_name": "120 ACTUAT mometasone furoate 0.05 MG/ACTUAT Metered Dose Inhaler [Asmanex]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2196900", "drug_name": "24 HR upadacitinib 15 MG Extended Release Oral Tablet [Rinvoq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2197501", "drug_name": "Fedratinib 100 MG Oral Capsule [Inrebic]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2197873", "drug_name": "entrectinib 100 MG Oral Capsule [Rozlytrek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2197877", "drug_name": "entrectinib 200 MG Oral Capsule [Rozlytrek]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2197890", "drug_name": "pitolisant 4.45 MG Oral Tablet [Wakix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2197894", "drug_name": "pitolisant 17.8 MG Oral Tablet [Wakix]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2198370", "drug_name": "pretomanid 200 MG Oral Tablet", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2198906", "drug_name": "influenza A virus A/Kansas/14/2017 (H3N2) antigen 158000000 UNT/ML / influenza A virus A/Switzerland/3330/2017 (H1N1) antigen 158000000 UNT/ML / influenza B virus B/Colorado/06/2017 antigen 158000000 UNT/ML / influenza B virus B/Phuket/3073/2013 antigen 158000000 UNT/ML Nasal Spray [FluMist Quadrivalent 2019-2020]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2198966", "drug_name": "Lefamulin 600 MG Oral Tablet [Xenleta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199026", "drug_name": "istradefylline 20 MG Oral Tablet [Nourianz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199030", "drug_name": "istradefylline 40 MG Oral Tablet [Nourianz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199304", "drug_name": "0.1 ML Glucagon 5 MG/ML Auto-Injector [Gvoke]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199308", "drug_name": "0.2 ML Glucagon 5 MG/ML Auto-Injector [Gvoke]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199312", "drug_name": "0.1 ML Glucagon 5 MG/ML Prefilled Syringe [Gvoke]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2199316", "drug_name": "0.2 ML Glucagon 5 MG/ML Prefilled Syringe [Gvoke]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200174", "drug_name": "Sprinkle duloxetine 20 MG Delayed Release Oral Capsule [Drizalma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200177", "drug_name": "Sprinkle duloxetine 30 MG Delayed Release Oral Capsule [Drizalma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200180", "drug_name": "Sprinkle duloxetine 40 MG Delayed Release Oral Capsule [Drizalma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200183", "drug_name": "Sprinkle duloxetine 60 MG Delayed Release Oral Capsule [Drizalma]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200291", "drug_name": "nabumetone 1000 MG Oral Tablet [Relafen]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200520", "drug_name": "Metformin hydrochloride 100 MG/ML Extended Release Suspension [Riomet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200650", "drug_name": "semaglutide 14 MG Oral Tablet [Rybelsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200654", "drug_name": "semaglutide 3 MG Oral Tablet [Rybelsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2200658", "drug_name": "semaglutide 7 MG Oral Tablet [Rybelsus]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2201540", "drug_name": "romiplostim 0.125 MG Injection [Nplate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2201578", "drug_name": "Baclofen 1 MG/ML Oral Solution [Ozobax]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2201640", "drug_name": "testosterone undecanoate 158 MG Oral Capsule [Jatenzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2201642", "drug_name": "testosterone undecanoate 198 MG Oral Capsule [Jatenzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2203893", "drug_name": "sofosbuvir 200 MG Oral Tablet [Sovaldi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2203897", "drug_name": "ledipasvir 45 MG / sofosbuvir 200 MG Oral Tablet [Harvoni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2203999", "drug_name": "sofosbuvir 150 MG Oral Pellet [Sovaldi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2204092", "drug_name": "sofosbuvir 200 MG Oral Pellet [Sovaldi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2204102", "drug_name": "ledipasvir 33.75 MG / sofosbuvir 150 MG Oral Pellet [Harvoni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2204104", "drug_name": "ledipasvir 45 MG / sofosbuvir 200 MG Oral Pellet [Harvoni]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205099", "drug_name": "60 ACTUAT aclidinium bromide 0.4 MG/ACTUAT / formoterol fumarate 0.012 MG/ACTUAT Dry Powder Inhaler [Duaklir]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205454", "drug_name": "3 ML insulin aspart, human 100 UNT/ML Cartridge [Fiasp]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205474", "drug_name": "baricitinib 1 MG Oral Tablet [Olumiant]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205618", "drug_name": "{9 (Azithromycin 500 MG Oral Tablet) } Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205634", "drug_name": "1 ML benralizumab 30 MG/ML Auto-Injector [Fasenra]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2205647", "drug_name": "trifarotene 0.05 MG/ML Topical Cream [Aklief]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2206092", "drug_name": "3 ML insulin, regular, human 100 UNT/ML Pen Injector [Novolin R]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2206099", "drug_name": "3 ML insulin isophane, human 100 UNT/ML Pen Injector [Novolin N]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2256943", "drug_name": "lasmiditan 100 MG Oral Tablet [Reyvow]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2256947", "drug_name": "lasmiditan 50 MG Oral Tablet [Reyvow]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2257013", "drug_name": "trikafta 100 MG / 50 MG / 75 MG and 150 MG Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2257015", "drug_name": "Osmolex 322 MG Daily Dosing Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2257678", "drug_name": "Minocycline 40 MG/ML Topical Foam [Amzeeq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2260709", "drug_name": "0.6 ML pegfilgrastim-bmez 10 MG/ML Prefilled Syringe [Ziextenzo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2261403", "drug_name": "Acetaminophen 21.7 MG/ML / butalbital 3.33 MG/ML / Caffeine 2.67 MG/ML Oral Solution [Vtol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2261794", "drug_name": "Diroximel fumarate 231 MG Delayed Release Oral Capsule [Vumerity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262032", "drug_name": "Amoxicillin 250 MG / Omeprazole 10 MG / Rifabutin 12.5 MG Delayed Release Oral Capsule [Talicia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262430", "drug_name": "10 ML crizanlizumab-tmca 10 MG/ML Injection [Adakveo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262446", "drug_name": "zanubrutinib 80 MG Oral Capsule [Brukinsa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262713", "drug_name": "Micronized Isotretinoin 16 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262719", "drug_name": "Micronized Isotretinoin 24 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262727", "drug_name": "Micronized Isotretinoin 32 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262731", "drug_name": "Micronized Isotretinoin 8 MG Oral Capsule [Absorica]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262911", "drug_name": "luspatercept-aamt 25 MG Injection [Reblozyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2262915", "drug_name": "luspatercept-aamt 75 MG Injection [Reblozyl]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2265689", "drug_name": "Voxelotor 500 MG Oral Tablet [Oxbryta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2265701", "drug_name": "Cenobamate 50 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2265729", "drug_name": "24 HR Asenapine 0.158 MG/HR Transdermal System [Secuado]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2265732", "drug_name": "24 HR Asenapine 0.238 MG/HR Transdermal System [Secuado]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2265735", "drug_name": "24 HR Asenapine 0.317 MG/HR Transdermal System [Secuado]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2266506", "drug_name": "21 DAY Ethinyl Estradiol 0.000625 MG/HR / Etonogestrel 0.005 MG/HR Vaginal System [EluRyng]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-ONE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2266816", "drug_name": "Amlodipine 10 MG / celecoxib 200 MG Oral Tablet [Consensi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2266818", "drug_name": "Amlodipine 5 MG / celecoxib 200 MG Oral Tablet [Consensi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2267566", "drug_name": "tazarotene 0.45 MG/ML Topical Lotion [Arazlo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2268227", "drug_name": "ubrogepant 100 MG Oral Tablet [Ubrelvy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2268231", "drug_name": "ubrogepant 50 MG Oral Tablet [Ubrelvy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2269079", "drug_name": "Clozapine 200 MG Oral Tablet [Clozaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2269081", "drug_name": "Clozapine 50 MG Oral Tablet [Clozaril]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272118", "drug_name": "avapritinib 100 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272122", "drug_name": "avapritinib 200 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272126", "drug_name": "avapritinib 300 MG Oral Tablet [Ayvakit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272414", "drug_name": "lemborexant 5 MG Oral Tablet [Dayvigo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272622", "drug_name": "VALTOCO 10 MG Dose Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272624", "drug_name": "VALTOCO 20 MG Dose Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272630", "drug_name": "VALTOCO 5 MG Dose Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2272636", "drug_name": "VALTOCO 15 MG Dose Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2273107", "drug_name": "24 HR budesonide 6 MG Extended Release Oral Capsule [Ortikos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2273110", "drug_name": "24 HR budesonide 9 MG Extended Release Oral Capsule [Ortikos]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2273115", "drug_name": "24 HR tofacitinib 22 MG Extended Release Oral Tablet [Xeljanz]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2274390", "drug_name": "tazemetostat 200 MG Oral Tablet [Tazverik]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2274814", "drug_name": "Jynarque 30 MG / 15 MG Carton Pack, 4 Blister Cards, 14 Capsules Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2274816", "drug_name": "Jynarque 15 MG / 15 MG Carton Pack, 4 Blister Cards, 14 Capsules Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2275613", "drug_name": "Lumateperone 42 MG Oral Capsule [Caplyta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2275729", "drug_name": "antihemophilic factor (recombinant) pegylated-exei 1 UNT Injection [Esperoct]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279419", "drug_name": "Palforzia Initial Dose Escalation Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279425", "drug_name": "Palforzia 40 MG (Level 5) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279427", "drug_name": "Palforzia 3 MG (Level 1) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279429", "drug_name": "Palforzia 6 MG (Level 2) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279435", "drug_name": "Palforzia 12 MG (Level 3) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279437", "drug_name": "Palforzia 20 MG (Level 4) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279439", "drug_name": "Palforzia 80 MG (Level 6) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279445", "drug_name": "Palforzia 120 MG (Level 7) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279447", "drug_name": "Palforzia 160 MG (Level 8) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279449", "drug_name": "Palforzia 200 MG (Level 9) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279451", "drug_name": "Palforzia 240 MG (Level 10) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279457", "drug_name": "Palforzia 300 MG (Level 11) Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279510", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 10 MG Oral Tablet [Prolate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279512", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 5 MG Oral Tablet [Prolate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2279514", "drug_name": "Acetaminophen 300 MG / Oxycodone Hydrochloride 7.5 MG Oral Tablet [Prolate]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2282320", "drug_name": "Rimegepant 75 MG Disintegrating Oral Tablet [Nurtec]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2282414", "drug_name": "bempedoic acid 180 MG Oral Tablet [Nexletol]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283236", "drug_name": "bempedoic acid 180 MG / ezetimibe 10 MG Oral Tablet [Nexlizet]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283505", "drug_name": "Cenobamate 100 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283509", "drug_name": "Cenobamate 150 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283513", "drug_name": "Cenobamate 200 MG Oral Tablet [Xcopri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283515", "drug_name": "Xcopri 250 MG Maintenance Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283518", "drug_name": "Xcopri 350 MG Maintenance Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283536", "drug_name": "Xcopri Titration Pack - 50 MG (14), 100 MG (14) 28 Count", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283538", "drug_name": "Xcopri Titration Pack - 12.5 MG (14), 25 MG (14) 28 Count", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2283540", "drug_name": "Xcopri Titration Pack - 150 MG (14), 200 MG (14) 28 Count", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2284104", "drug_name": "palbociclib 100 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2284106", "drug_name": "palbociclib 125 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2284108", "drug_name": "palbociclib 75 MG Oral Tablet [Ibrance]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2284514", "drug_name": "Cysteamine 300 MG Delayed Release Oral Granules [Procysbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2284516", "drug_name": "Cysteamine 75 MG Delayed Release Oral Granules [Procysbi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2286261", "drug_name": "Dexamethasone 20 MG Oral Tablet [Hemady]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2286281", "drug_name": "osilodrostat 1 MG Oral Tablet [Isturisa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2286285", "drug_name": "osilodrostat 10 MG Oral Tablet [Isturisa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2286290", "drug_name": "osilodrostat 5 MG Oral Tablet [Isturisa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2287905", "drug_name": "1.5 ML fremanezumab-vfrm 150 MG/ML Auto-Injector [Ajovy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2288412", "drug_name": "ozanimod 0.92 MG Oral Capsule [Zeposia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2288427", "drug_name": "lemborexant 10 MG Oral Tablet [Dayvigo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2288431", "drug_name": "Zepsoia Starter Kit (7-Day Starter Pack and 0.92 MG 30 count Bottle)", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2288433", "drug_name": "Zeposia 7-Day Starter Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2288816", "drug_name": "sofosbuvir 200 MG / velpatasvir 50 MG Oral Tablet [Epclusa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2289424", "drug_name": "selumetinib 10 MG Oral Capsule [Koselugo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2289428", "drug_name": "selumetinib 25 MG Oral Capsule [Koselugo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359285", "drug_name": "24 HR empagliflozin 10 MG / linagliptin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359290", "drug_name": "24 HR empagliflozin 12.5 MG / linagliptin 2.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359340", "drug_name": "pemigatinib 13.5 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359344", "drug_name": "pemigatinib 4.5 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359348", "drug_name": "pemigatinib 9 MG Oral Tablet [Pemazyre]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359353", "drug_name": "24 HR empagliflozin 25 MG / linagliptin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2359358", "drug_name": "24 HR empagliflozin 5 MG / linagliptin 2.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Trijardy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2360548", "drug_name": "2.8 ML octreotide 2.5 MG/ML Pen Injector [Bynfezia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2360588", "drug_name": "0.5 ML Neisseria meningitidis serogroup A capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup C capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup W-135 capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML / Neisseria meningitidis serogroup Y capsular polysaccharide tetanus toxoid protein conjugate vaccine 0.02 MG/ML Injection [Menquadfi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2360884", "drug_name": "doxycycline hyclate 80 MG Delayed Release Oral Tablet [Doryx]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2361296", "drug_name": "tucatinib 150 MG Oral Tablet [Tukysa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2361300", "drug_name": "tucatinib 50 MG Oral Tablet [Tukysa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2361313", "drug_name": "nimodipine 6 MG/ML Oral Solution [Nymalize]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2362182", "drug_name": "opicapone 50 MG Oral Capsule [Ongentys]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2362240", "drug_name": "capmatinib 150 MG Oral Tablet [Tabrecta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2362244", "drug_name": "capmatinib 200 MG Oral Tablet [Tabrecta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2369403", "drug_name": "ripretinib 50 MG Oral Tablet [Qinlock]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2370170", "drug_name": "selpercatinib 40 MG Oral Capsule [Retevmo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2370174", "drug_name": "selpercatinib 80 MG Oral Capsule [Retevmo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371050", "drug_name": "apomorphine hydrochloride 10 MG Sublingual Film [Kynmobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371054", "drug_name": "apomorphine hydrochloride 15 MG Sublingual Film [Kynmobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371058", "drug_name": "apomorphine hydrochloride 20 MG Sublingual Film [Kynmobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371062", "drug_name": "apomorphine hydrochloride 25 MG Sublingual Film [Kynmobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371066", "drug_name": "apomorphine hydrochloride 30 MG Sublingual Film [Kynmobi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2371768", "drug_name": "Oriahnn 28 Day Kit", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2372911", "drug_name": "Once-Daily diclofenac epolamine 0.013 MG/MG Medicated Patch [Licart]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2373941", "drug_name": "bedaquiline 20 MG Oral Tablet [Sirturo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2374566", "drug_name": "dolutegravir 5 MG Tablet for Oral Suspension [Tivicay]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2375329", "drug_name": "2 ML dupilumab 150 MG/ML Auto-Injector [Dupixent]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2375338", "drug_name": "minocycline 15 MG/ML Topical Foam [Zilxi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2377134", "drug_name": "insulin glargine 100 UNT/ML Injectable Solution [Semglee]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2377231", "drug_name": "3 ML insulin glargine 100 UNT/ML Pen Injector [Semglee]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2377369", "drug_name": "levamlodipine 2.5 MG Oral Tablet [Conjupri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2377373", "drug_name": "levamlodipine 5 MG Oral Tablet [Conjupri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2379638", "drug_name": "0.5 ML influenza A virus A/Guangdong-Maonan/SWL1536/2019 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.03 MG/ML Prefilled Syringe [Fluarix Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2379736", "drug_name": "0.5 ML influenza A virus A/Guangdong-Maonan/SWL1536/2019 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.03 MG/ML Prefilled Syringe [Flulaval Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380236", "drug_name": "insulin lispro-aabc 100 UNT/ML Injectable Solution [Lyumjev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380256", "drug_name": "3 ML insulin lispro-aabc 200 UNT/ML Pen Injector [Lyumjev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380260", "drug_name": "3 ML insulin lispro-aabc 100 UNT/ML Pen Injector [Lyumjev]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380551", "drug_name": "12 HR fostemsavir 600 MG Extended Release Oral Tablet [Rukobia]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380570", "drug_name": "metoclopramide 15 MG/ACTUAT Nasal Spray [Gimoti]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380581", "drug_name": "influenza A virus A/Guangdong-Maonan/SWL1536/2019 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.03 MG/ML Injectable Suspension [Fluzone Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380588", "drug_name": "0.5 ML influenza A virus A/Guangdong-Maonan/SWL1536/2019 (H1N1) antigen 0.03 MG/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.03 MG/ML Injection [Fluzone Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380600", "drug_name": "0.5 ML influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Victoria/2454/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Victoria/705/2018 antigen 0.03 MG/ML Prefilled Syringe [Afluria Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380604", "drug_name": "0.25 ML influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Victoria/2454/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Victoria/705/2018 antigen 0.03 MG/ML Prefilled Syringe [Afluria Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380607", "drug_name": "influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Victoria/2454/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Victoria/705/2018 antigen 0.03 MG/ML Injectable Suspension [Afluria Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380617", "drug_name": "octreotide 20 MG Delayed Release Oral Capsule [Mycapssa]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380848", "drug_name": "influenza A virus A/Delaware/39/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Nebraska/14/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Darwin/7/2019 antigen 0.03 MG/ML / influenza B virus B/Singapore/INFTT-16-0610/2016 antigen 0.03 MG/ML Injectable Suspension [Flucelvax Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380851", "drug_name": "0.5 ML influenza A virus A/Delaware/39/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Nebraska/14/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Darwin/7/2019 antigen 0.03 MG/ML / influenza B virus B/Singapore/INFTT-16-0610/2016 antigen 0.03 MG/ML Prefilled Syringe [Flucelvax Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2380863", "drug_name": "0.5 ML influenza A virus A/Hawaii/70/2019 (H1N1) antigen 0.09 MG/ML / influenza A virus A/Minnesota/41/2019 (H3N2) antigen 0.09 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.09 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.09 MG/ML Prefilled Syringe [Flublok Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2381144", "drug_name": "fenfluramine 2.2 MG/ML Oral Solution [Fintepla]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2381150", "drug_name": "0.5 ML influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Victoria/2454/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Victoria/705/2018 antigen 0.03 MG/ML Prefilled Syringe [Fluad 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2382439", "drug_name": "0.5 ML influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.03 MG/ML / influenza A virus A/Victoria/2454/2019 (H1N1) antigen 0.03 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.03 MG/ML / influenza B virus B/Victoria/705/2018 antigen 0.03 MG/ML Prefilled Syringe [Fluad Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2382990", "drug_name": "Xpovio 60 MG Twice Weekly (120 MG total weekly) Dose Carton Pack, 4 Blister Cards, 6 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2382991", "drug_name": "Xpovio 40 MG Twice Weekly (80 MG total weekly) Dose Carton Pack, 4 Blister Cards, 4 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2382993", "drug_name": "Xpovio 40 MG Weekly Dose Carton Pack, 4 Blister Cards, 2 Tablets Each", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2383548", "drug_name": "0.7 ML influenza A virus A/Guangdong-Maonan/SWL1536/2019 (H1N1) antigen 0.0857 MG/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 0.0857 MG/ML / influenza B virus B/Phuket/3073/2013 antigen 0.0857 MG/ML / influenza B virus B/Washington/02/2019 antigen 0.0857 MG/ML Prefilled Syringe [Fluzone Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2383561", "drug_name": "triheptanoin 1000 MG/ML Oral Solution [Dojolvi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2384465", "drug_name": "Inqovi 5 Tablet Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2385353", "drug_name": "citric acid 0.01 MG/MG / lactic acid 0.018 MG/MG / potassium bitartrate 0.004 MG/MG Vaginal Gel [Phexxi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2386870", "drug_name": "coagulation factor VIIa (recombinant)-jncw 5 MG Injection [Sevenfact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2386874", "drug_name": "coagulation factor VIIa (recombinant)-jncw 1 MG Injection [Sevenfact]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2387328", "drug_name": "28 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.009 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2387331", "drug_name": "120 ACTUAT budesonide 0.16 MG/ACTUAT / formoterol fumarate 0.0048 MG/ACTUAT / glycopyrrolate 0.009 MG/ACTUAT Metered Dose Inhaler [Breztri]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2387356", "drug_name": "Zcort 1.5 MG Tablet 7 Day 25 Count Pack", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2389313", "drug_name": "influenza A virus A/Hawaii/66/2019 (H1N1) antigen 158000000 UNT/ML / influenza A virus A/Hong Kong/2671/2019 (H3N2) antigen 158000000 UNT/ML / influenza B virus B/Phuket/3073/2013 antigen 158000000 UNT/ML / influenza B virus B/Washington/02/2019 antigen 158000000 UNT/ML Nasal Spray [Flumist Quadrivalent 2020-2021]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2390946", "drug_name": "Risdiplam 0.75 MG/ML Oral Solution [Evrysdi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2390954", "drug_name": "0.4 ML ofatumumab 50 MG/ML Pen Injector [Kesimpta]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2391560", "drug_name": "1 ML satralizumab-mwge 120 MG/ML Prefilled Syringe [Enspryng]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2391754", "drug_name": "oxymetazoline hydrochloride 1 MG/ML Ophthalmic Solution [Upneeq]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2393593", "drug_name": "monomethyl fumarate 95 MG Delayed Release Oral Capsule [Bafiertam]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2393794", "drug_name": "calcium oxybate 234 MG/ML / magnesium oxybate 96 MG/ML / potassium oxybate 130 MG/ML / sodium oxybate 40 MG/ML Oral Solution [Xywav]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2394947", "drug_name": "pralsetinib 100 MG Oral Capsule [Gavreto]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395771", "drug_name": "14 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395775", "drug_name": "30 ACTUAT fluticasone furoate 0.2 MG/ACTUAT / umeclidinium 0.0625 MG/ACTUAT / vilanterol 0.025 MG/ACTUAT Dry Powder Inhaler [Trelegy]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395779", "drug_name": "0.5 ML dulaglutide 6 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395785", "drug_name": "0.5 ML dulaglutide 9 MG/ML Auto-Injector [Trulicity]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395814", "drug_name": "tramadol hydrochloride 5 MG/ML Oral Solution [Qdolo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395828", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.113 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395831", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.055 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395834", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.232 MG/ACTUAT / salmeterol 0.014 MG/ACTUAT Dry Powder Inhaler [AirDuo]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395836", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.113 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395838", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.232 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2395840", "drug_name": "Sensor 60 ACTUAT fluticasone propionate 0.055 MG/ACTUAT Dry Powder Inhaler [Armonair]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2396259", "drug_name": "Twirla 3 Count Weekly Transdermal System", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2396770", "drug_name": "azacitidine 200 MG Oral Tablet [Onureg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2396774", "drug_name": "azacitidine 300 MG Oral Tablet [Onureg]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": true, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2396905", "drug_name": "cysteamine 3.8 MG/ML Ophthalmic Solution [Cystadrops]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-TWO", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2021 ] } ] }, { "rxnorm_id": "2397991", "drug_name": "nifurtimox 30 MG Oral Tablet [Lampit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2397994", "drug_name": "nifurtimox 120 MG Oral Tablet [Lampit]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2399650", "drug_name": "hydrocortisone 0.5 MG Oral Granules [Alkindi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2399654", "drug_name": "hydrocortisone 1 MG Oral Granules [Alkindi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2399658", "drug_name": "hydrocortisone 2 MG Oral Granules [Alkindi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] }, { "rxnorm_id": "2399661", "drug_name": "hydrocortisone 5 MG Oral Granules [Alkindi]", "plans": [ { "plan_id_type": "HIOS-PLAN-ID", "plan_id": "12345PA0010001", "drug_tier": "TIER-THREE", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2021 ] } ] } ]