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"prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307668", "drug_name": "acetaminophen 32 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198440", "drug_name": "acetaminophen 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310604", "drug_name": "guaifenesin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000990", "drug_name": "oxymetazoline hydrochloride 0.5 MG/ML Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308753", "drug_name": "bisacodyl 5 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978010", "drug_name": "loperamide hydrochloride 2 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "318272", "drug_name": "aspirin 81 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "880407", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [ClearLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1188426", "drug_name": "carboxymethylcellulose sodium 5 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049906", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313782", "drug_name": "acetaminophen 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198852", "drug_name": "simethicone 125 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049160", "drug_name": "pseudoephedrine hydrochloride 30 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1101446", "drug_name": "doxylamine succinate 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049630", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1148399", "drug_name": "8 HR acetaminophen 650 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1044949", "drug_name": "dextromethorphan hydrobromide 2 MG/ML / guaifenesin 20 MG/ML / phenylephrine hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1043543", "drug_name": "dextromethorphan hydrobromide 1 MG/ML / guaifenesin 20 MG/ML / phenylephrine hydrochloride 0.5 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212033", "drug_name": "aspirin 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1736014", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Option 2]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298324", "drug_name": "12 HR dextromethorphan hydrobromide 30 MG / guaifenesin 600 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310621", "drug_name": "12 HR guaifenesin 1200 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1305603", "drug_name": "12 HR guaifenesin 600 MG / pseudoephedrine hydrochloride 60 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "253017", "drug_name": "magnesium hydroxide 80 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310323", "drug_name": "ferrous sulfate 60 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308891", "drug_name": "calcium carbonate 250 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995868", "drug_name": "codeine phosphate 2 MG/ML / guaifenesin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245686", "drug_name": "docusate sodium 10 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "307675", "drug_name": "acetaminophen 32 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "251154", "drug_name": "cholecalciferol 0.01 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237870", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702311", "drug_name": "sennosides, USP 1.76 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1115005", "drug_name": "docusate sodium 100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308749", "drug_name": "bisacodyl 0.333 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1190433", "drug_name": "glycerin 1037 MG/ML Enema [Pedia-Lax Liquid Glycerin Suppositories]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309594", "drug_name": "vitamin B12 1 MG/ML Injectable Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310410", "drug_name": "folic acid 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198641", "drug_name": "folic acid 0.8 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198946", "drug_name": "vitamin B6 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198859", "drug_name": "sodium bicarbonate 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198861", "drug_name": "sodium bicarbonate 650 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1101836", "drug_name": "trolamine salicylate 100 MG/ML Topical Cream [Mobisyl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "707359", "drug_name": "sodium chloride 6.5 MG/ML Nasal Spray [Ayr Saline Nasal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "707333", "drug_name": "sodium chloride 6.5 MG/ML Nasal Solution [Ayr Saline Nasal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310324", "drug_name": "ferrous sulfate 325 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246075", "drug_name": "pramoxine hydrochloride 10 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998740", "drug_name": "docusate sodium 50 MG / sennosides, USP 8.6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "283100", "drug_name": "sodium phosphate, dibasic 59.3 MG/ML / sodium phosphate, monobasic 161 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "251020", "drug_name": "sennosides, USP 15 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205121", "drug_name": "mineral oil 1000 MG/ML Enema", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1086767", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution [Wal-Dryl Childrens]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090076", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule [Wal-Dryl Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198509", "drug_name": "bisacodyl 10 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049551", "drug_name": "pseudoephedrine hydrochloride 30 MG Oral Tablet [Wal-Phed]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308934", "drug_name": "calcium polycarbophil 625 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1052760", "drug_name": "magnesium citrate 58.2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312935", "drug_name": "sennosides, USP 8.6 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308915", "drug_name": "calcium carbonate 750 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308907", "drug_name": "calcium carbonate 500 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198467", "drug_name": "aspirin 325 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308416", "drug_name": "aspirin 81 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "876193", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090078", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet [Wal-Dryl Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308892", "drug_name": "calcium carbonate 1000 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1746511", "drug_name": "doxylamine succinate 25 MG Oral Tablet [Wal-Som (doxylamine)]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978006", "drug_name": "loperamide hydrochloride 2 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "996520", "drug_name": "dextromethorphan hydrobromide 2 MG/ML / guaifenesin 20 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "707251", "drug_name": "sodium chloride 6.5 MG/ML Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "705909", "drug_name": "mineral oil 999 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298435", "drug_name": "sodium chloride 0.000855 MEQ/MG Ophthalmic Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308761", "drug_name": "bismuth subsalicylate 262 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363306", "drug_name": "chlorpheniramine maleate 0.4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1358627", "drug_name": "guaifenesin 20 MG/ML / phenylephrine hydrochloride 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1101778", "drug_name": "monobasic potassium phosphate 0.0408 MEQ/ML Oral Solution [K-Phos]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251241", "drug_name": "potassium phosphate 155 MG / sodium phosphate, dibasic 852 MG / sodium phosphate, monobasic 130 MG Oral Tablet [K-Phos Neutral]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "210000", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension [Almacone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363315", "drug_name": "chlorpheniramine maleate 4 MG Oral Tablet [Aller-Chlor]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998704", "drug_name": "calcium carbonate 500 MG Chewable Tablet [Cal Gest]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310325", "drug_name": "ferrous sulfate 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "483325", "drug_name": "levonorgestrel 1.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1248013", "drug_name": "docusate sodium 50 MG / sennosides, USP 8.6 MG Oral Tablet [Senexon S]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "730780", "drug_name": "sodium chloride 0.854 MEQ/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1248119", "drug_name": "docusate sodium 10 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "412113", "drug_name": "vitamin E 180 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "804146", "drug_name": "cholecalciferol 0.05 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309593", "drug_name": "vitamin B12 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702249", "drug_name": "ferrous sulfate 44 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309604", "drug_name": "vitamin B12 0.25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1606850", "drug_name": "guaifenesin 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204642", "drug_name": "selenium sulfide 10 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "282402", "drug_name": "ascorbic acid 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1100457", "drug_name": "pyridoxine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1297389", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 200 UNT Oral Tablet [Oysco 500 with D]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198630", "drug_name": "ferrous gluconate 324 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1860100", "drug_name": "ferrous sulfate 324 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198741", "drug_name": "magnesium oxide 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311430", "drug_name": "magnesium oxide 420 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313861", "drug_name": "beta carotene 25000 UNT Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "240952", "drug_name": "biotin 1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308744", "drug_name": "biotin 5 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199362", "drug_name": "cholecalciferol 0.025 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "252732", "drug_name": "melatonin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198538", "drug_name": "calcium citrate 950 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "210467", "drug_name": "vitamin E 100 UNT Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309595", "drug_name": "vitamin B12 0.1 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198897", "drug_name": "ascorbic acid 1000 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "639566", "drug_name": "vitamin B6 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313896", "drug_name": "vitamin B12 0.5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198891", "drug_name": "vitamin B12 2.5 MG Sublingual Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313323", "drug_name": "thiamine 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809533", "drug_name": "calcium carbonate 1500 MG / cholecalciferol 200 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198640", "drug_name": "folic acid 0.4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "205643", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion [Amlactin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "343017", "drug_name": "mineral oil 1000 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1363309", "drug_name": "chlorpheniramine maleate 4 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "260476", "drug_name": "vitamin E 450 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "282465", "drug_name": "calcium carbonate 1250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020477", "drug_name": "diphenhydramine hydrochloride 50 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313638", "drug_name": "vitamin A 10000 UNT Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284308", "drug_name": "calcium polycarbophil 625 MG Oral Tablet [Fiber Tab]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "707381", "drug_name": "sodium chloride 6.5 MG/ML Nasal Spray [Deep Sea]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311431", "drug_name": "magnesium oxide 500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049162", "drug_name": "pseudoephedrine hydrochloride 30 MG Oral Tablet [Sudogest]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020479", "drug_name": "diphenhydramine hydrochloride 50 MG Oral Capsule [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998254", "drug_name": "chlorpheniramine maleate 4 MG / pseudoephedrine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "809536", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 200 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1092421", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Tablet [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "708127", "drug_name": "aluminum hydroxide 80 MG/ML / magnesium hydroxide 80 MG/ML / simethicone 8 MG/ML Oral Suspension [Mintox Plus]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309263", "drug_name": "cholecalciferol 0.01 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "543460", "drug_name": "ammonium lactate 120 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197362", "drug_name": "ammonium lactate 120 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "261385", "drug_name": "ferrous gluconate 240 MG Oral Tablet [Ferate]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "702050", "drug_name": "carbamide peroxide 65 MG/ML Otic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209870", "drug_name": "acetaminophen 160 MG Chewable Tablet [Mapap]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049169", "drug_name": "pseudoephedrine hydrochloride 60 MG Oral Tablet [Sudogest]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049167", "drug_name": "pseudoephedrine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314216", "drug_name": "simethicone 80 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1092422", "drug_name": "diphenhydramine hydrochloride 25 MG Oral Capsule [Banophen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245468", "drug_name": "docusate sodium 250 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1251355", "drug_name": "aluminum hydroxide 6.33 MG/ML / magnesium carbonate 23.9 MG/ML Oral Suspension [Acid Gone]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "245500", "drug_name": "cholecalciferol 0.025 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199163", "drug_name": "melatonin 3 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "435020", "drug_name": "cholecalciferol 0.01 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204625", "drug_name": "riboflavin 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "857466", "drug_name": "cholecalciferol 0.125 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049909", "drug_name": "diphenhydramine hydrochloride 25 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false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204624", "drug_name": "riboflavin 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199083", "drug_name": "ascorbic acid 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313326", "drug_name": "thiamine 250 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313803", "drug_name": "ascorbic acid 500 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209638", "drug_name": "cholecalciferol 0.01 MG Oral Tablet [Delta D3]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308382", "drug_name": "ascorbic acid 1000 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198507", "drug_name": "biotin 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237776", "drug_name": "vitamin B12 1 MG Extended Release Oral 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"step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "242590", "drug_name": "ferrous gluconate 240 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310318", "drug_name": "ferrous sulfate 160 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245376", "drug_name": "docusate calcium 240 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "428485", "drug_name": "calcium carbonate 1500 MG / cholecalciferol 0.01 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "309714", "drug_name": "dextran 70 1 MG/ML / hypromellose 3 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1190600", "drug_name": "dexbrompheniramine maleate 0.133 MG/ML / dextromethorphan hydrobromide 2 MG/ML / pseudoephedrine hydrochloride 4 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1367410", "drug_name": "ergocalciferol 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213158", "drug_name": "guaifenesin 20 MG/ML Oral Solution [Scot-Tussin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237420", "drug_name": "calcium carbonate 1500 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2003710", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [New Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891719", "drug_name": "ascorbic acid 200 MG / beta carotene 1000 UNT / cuprous oxide 2 MG / dl-alpha tocopheryl acetate 60 UNT / lutein 2 MG / sodium selenate 0.055 MG / zinc oxide 40 MG Oral Tablet [Ocuvite]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891709", "drug_name": "ascorbic acid 60 MG / cuprous oxide 2 MG / dl-alpha tocopheryl acetate 30 MG / lutein 6 MG / zinc oxide 15 MG Oral Capsule [Ocuvite Lutein]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891815", "drug_name": "ascorbic acid 113 MG / beta carotene 7160 MG / cuprous oxide 0.4 MG / dl-alpha tocopheryl acetate 100 UNT / zinc oxide 17.4 MG Oral Tablet [PreserVision]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891793", "drug_name": "ascorbic acid 226 MG / beta carotene 14320 UNT / cuprous oxide 0.8 MG / dl-alpha tocopheryl acetate 200 UNT / zinc oxide 34.8 MG Oral Capsule [PreserVision]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "891820", "drug_name": "ascorbic acid 226 MG / cuprous oxide 0.8 MG / dl-alpha tocopheryl acetate 200 UNT / lutein 5 MG / zinc oxide 34.8 MG Oral Capsule [PreserVision with Lutein]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "824586", "drug_name": "psyllium 3400 MG Powder for Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049423", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [GentleLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313652", "drug_name": "vitamin A 2.4 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1095421", "drug_name": "ferrous sulfate 140 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313713", "drug_name": "vitamin E 90 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "847121", "drug_name": "calcium citrate 1500 MG / cholecalciferol 250 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204623", "drug_name": "riboflavin 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "876214", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [Gavilax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198443", "drug_name": "acetaminophen 650 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198434", "drug_name": "acetaminophen 120 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313820", "drug_name": "acetaminophen 160 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1049900", "drug_name": "diphenhydramine hydrochloride 12.5 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "636811", "drug_name": "melatonin 0.25 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978012", "drug_name": "loperamide hydrochloride 2 MG Oral Tablet [Diamode]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "237723", "drug_name": "ergocalciferol 0.2 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "763296", "drug_name": "sennosides, USP 8.6 MG Oral Tablet [Senna-Time]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600602", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [EContra]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "880340", "drug_name": "cholecalciferol 0.025 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1855519", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Her Style]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1650274", "drug_name": "cholecalciferol 0.375 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2749389", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Your Choice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "705728", "drug_name": "cholecalciferol 1.25 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209531", "drug_name": "acetaminophen 80 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209353", "drug_name": "acetaminophen 120 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "209361", "drug_name": "acetaminophen 325 MG Rectal Suppository [Feverall]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404369", "drug_name": "ferrous fumarate 324 MG Oral Tablet [Ferrocite]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308384", "drug_name": "ascorbic acid 250 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1090824", "drug_name": "ascorbic acid 60 MG / beta carotene 5000 UNT / copper sulfate 40 MG / dl-alpha tocopheryl acetate 30 UNT / sodium selenite 0.04 MG / zinc oxide 40 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "251156", "drug_name": "ferrous sulfate 75 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "213160", "drug_name": "guaifenesin 20 MG/ML Oral Solution [Siltussin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1094393", "drug_name": "diphenhydramine hydrochloride 2.5 MG/ML Oral Solution [Siladryl]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "284283", "drug_name": "bisacodyl 10 MG Rectal Suppository [The Magic Bullet]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "308377", "drug_name": "ascorbic acid 100 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "150921", "drug_name": "thiamine 50 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "252062", "drug_name": "glycerin 1000 MG Rectal Suppository", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1593876", "drug_name": "sodium chloride 6.5 MG/ML Nasal Spray [Altamist]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1010732", "drug_name": "polyethylene glycol 3350 17000 MG Powder for Oral Solution [PureLax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1094109", "drug_name": "phenazopyridine hydrochloride 100 MG Oral Tablet [Pyridium]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1094122", "drug_name": "phenazopyridine hydrochloride 200 MG Oral Tablet [Pyridium]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1549091", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Opcicon One-Step]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1922759", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [My Choice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1368932", "drug_name": "riboflavin 400 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1788864", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [React]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "656742", "drug_name": "potassium phosphate 155 MG / sodium phosphate, dibasic 852 MG / sodium phosphate, monobasic 130 MG Oral Tablet [Phospha 250 Neutral]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1435917", "drug_name": "cholecalciferol 0.625 MG Oral Capsule [Decara]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1426881", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [My Way]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1598658", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Aftera]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1490063", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Take Action]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "314221", "drug_name": "simethicone 125 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "313518", "drug_name": "trolamine salicylate 100 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "312881", "drug_name": "salicylic acid 170 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "238784", "drug_name": "dibucaine 0.01 MG/MG Rectal Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "243670", "drug_name": "aspirin 81 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "212033", "drug_name": "aspirin 325 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2631024", "drug_name": "levonorgestrel 1.5 MG Oral Tablet [Curae]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1089355", "drug_name": "psyllium 3400 MG Powder for Oral Suspension [Reguloid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "801663", "drug_name": "cholecalciferol 0.05 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2707116", "drug_name": "ascorbic acid 100 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1233607", "drug_name": "calcium carbonate 1250 MG / cholecalciferol 600 UNT Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "885578", "drug_name": "24 HR ferrous sulfate 142 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "COVERED", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1000089", "drug_name": "alcaftadine 2.5 MG/ML Ophthalmic Solution [Lastacaft]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2474007", "drug_name": "olopatadine 7 MG/ML Ophthalmic Solution [Pataday]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111345", "drug_name": "olopatadine 2 MG/ML Ophthalmic Solution [Pataday]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "311372", "drug_name": "loratadine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198031", "drug_name": "24 HR nicotine 0.292 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "213626", "drug_name": "bacitracin 0.5 UNT/MG / polymyxin B 10 UNT/MG Topical Ointment [Polysporin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1043063", "drug_name": "hydrocortisone 10 MG/ML Topical Lotion [Aquanil HC]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797907", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283641", "drug_name": "calcium carbonate 800 MG / famotidine 10 MG / magnesium hydroxide 165 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "616539", "drug_name": "omeprazole 20 MG / sodium bicarbonate 1100 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "992766", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream) / 3 (miconazole nitrate 200 MG 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"PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2003656", "drug_name": "omeprazole 20 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "402014", "drug_name": "omeprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797870", "drug_name": "mometasone furoate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Nasonex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310963", "drug_name": "ibuprofen 100 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "596918", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule [Prevacid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1117562", "drug_name": "24 HR loratadine 10 MG / pseudoephedrine sulfate 240 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "209326", "drug_name": "nicotine 2 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "105071", "drug_name": "nicotine 4 MG Chewing Gum [Nicorette]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "855205", "drug_name": "docosanol 100 MG/ML Topical Cream [Abreva]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1869712", "drug_name": "fluticasone furoate 0.0275 MG/ACTUAT Metered Dose Nasal Spray [Flonase Sensimist]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2709228", "drug_name": "miconazole nitrate 20 MG/ML Topical Cream [Desenex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "197505", "drug_name": "cimetidine 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198051", "drug_name": "omeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1482533", "drug_name": "cetirizine hydrochloride 1 MG/ML Oral Solution [Wal Zyr 24 Hour Allergy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "755478", "drug_name": "loratadine 1 MG/ML Oral Solution [Wal-itin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199047", "drug_name": "famotidine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1358471", "drug_name": "loratadine 10 MG Disintegrating Oral Tablet [Wal-itin]", 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"plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1192737", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet [Wal-Fex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014580", "drug_name": "12 HR cetirizine hydrochloride 5 MG / pseudoephedrine hydrochloride 120 MG Extended Release Oral Tablet [Wal Zyr D]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1862280", "drug_name": "loratadine 10 MG Oral Capsule [Wal-itin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797865", "drug_name": "mometasone furoate 0.05 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "992528", "drug_name": "terbinafine hydrochloride 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1011482", "drug_name": "cetirizine hydrochloride 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1246673", "drug_name": "ivermectin 5 MG/ML Topical Lotion", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111339", "drug_name": "olopatadine 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "103951", "drug_name": "tolnaftate 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "884655", "drug_name": "amphetamine sulfate 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600695", "drug_name": "amphetamine sulfate 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1313059", "drug_name": "24 HR phentermine 11.25 MG / topiramate 69 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302850", "drug_name": "24 HR phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302827", "drug_name": "24 HR phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1302839", "drug_name": "24 HR phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "978654", "drug_name": "diethylpropion hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797929", "drug_name": "budesonide 0.032 MG/ACTUAT Metered Dose Nasal Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "309370", "drug_name": "clotrimazole 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992816", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream) / 3 (5000 MG) (miconazole nitrate 40 MG/ML Vaginal Cream) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "153008", "drug_name": "ibuprofen 200 MG Oral Tablet [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "206878", "drug_name": "ibuprofen 20 MG/ML Oral Suspension [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "731533", "drug_name": "ibuprofen 200 MG Oral Capsule [Advil]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014674", "drug_name": "cetirizine hydrochloride 10 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "998526", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution [Fungoid]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "692783", "drug_name": "loratadine 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "997501", "drug_name": "fexofenadine hydrochloride 60 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "992536", "drug_name": "terbinafine hydrochloride 10 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"NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "668469", "drug_name": "loratadine 5 MG Chewable Tablet [Claritin]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1359350", "drug_name": "bacitracin 0.5 UNT/MG / neomycin 0.0035 MG/MG / polymyxin B 10 UNT/MG / pramoxine hydrochloride 0.01 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600700", "drug_name": "amphetamine sulfate 5 MG Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1600698", "drug_name": "amphetamine sulfate 10 MG Oral Tablet [Evekeo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1298427", "drug_name": "ivermectin 5 MG/ML Topical Lotion [Sklice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1245186", "drug_name": "dimenhydrinate 25 MG Chewable Tablet [Dramamine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "602223", "drug_name": "dimenhydrinate 50 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"PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1010895", "drug_name": "lidocaine hydrochloride 40 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855633", "drug_name": "diclofenac sodium 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1737778", "drug_name": "lidocaine 0.04 MG/MG Medicated Patch", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "794244", "drug_name": "capsaicin 1 MG/ML Topical Cream [Capzasin-HP]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855170", "drug_name": "levocetirizine dihydrochloride 0.5 MG/ML Oral Solution [Xyzal]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "849612", "drug_name": "Fe heme polypeptide 6 MG / polysaccharide iron complex 22 MG Oral Tablet [Bifera]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1112231", "drug_name": "naproxen sodium 220 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311373", "drug_name": "loratadine 10 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1987647", "drug_name": "lidocaine hydrochloride 40 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014643", "drug_name": "cetirizine hydrochloride 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020126", "drug_name": "loratadine 10 MG Oral Tablet [Loradamed]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "665078", "drug_name": "loratadine 5 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "313423", "drug_name": "tolnaftate 10 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "828269", "drug_name": "loratadine 10 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242401", "drug_name": "12 HR loratadine 5 MG / pseudoephedrine sulfate 120 MG Extended Release Oral Tablet [Alavert D]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "577395", "drug_name": "capsaicin 0.35 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020026", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1020022", "drug_name": "cetirizine hydrochloride 10 MG Chewable Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1011485", "drug_name": "cetirizine hydrochloride 10 MG Disintegrating Oral Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2558503", "drug_name": "cetirizine hydrochloride 2.5 MG Chewable Tablet [Zyrtec]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2265266", "drug_name": "loratadine 10 MG Chewable Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "608844", "drug_name": "ketoconazole 10 MG/ML Medicated Shampoo [Nizoral]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "242668", "drug_name": "ascorbic acid 250 MG / iron carbonyl 100 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "803354", "drug_name": "phentermine hydrochloride 37.5 MG Oral Tablet [Adipex-P]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2058508", "drug_name": "piperonyl butoxide 0.035 MG/MG / pyrethrins 0.003 MG/MG Topical Gel [Vanalice]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "998525", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2735135", "drug_name": "miconazole nitrate 0.02 MG/MG Topical Gel [Lasolex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198555", "drug_name": "capsaicin 0.25 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2746503", "drug_name": "miconazole nitrate 20 MG/ML Topical Solution [Lasolex]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1010835", "drug_name": "lidocaine hydrochloride 30 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "200083", "drug_name": "capsaicin 0.5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "226917", "drug_name": "orlistat 120 MG Oral Capsule [Xenical]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "314153", "drug_name": "orlistat 120 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "998541", "drug_name": "miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1661176", "drug_name": "tioconazole 0.065 MG/MG Vaginal Ointment [Monistat Simple Therapy]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992784", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]) / 1 (45000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream [Monistat]) } Pack [Monistat 7 Vaginal Cream Combination Pack]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1797909", "drug_name": "fluticasone propionate 0.05 MG/ACTUAT Metered Dose Nasal Spray [Aller-Flo]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014573", "drug_name": "12 HR cetirizine hydrochloride 5 MG / pseudoephedrine hydrochloride 120 MG Extended Release Oral Tablet [Aller-Tec D]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1369756", "drug_name": "24 HR loratadine 10 MG / pseudoephedrine sulfate 240 MG Extended Release Oral Tablet [Allerclear]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "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": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995634", "drug_name": "meclizine hydrochloride 25 MG Chewable Tablet [Bonine]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1087410", "drug_name": "24 HR ascorbic acid 500 MG / biotin 0.15 MG / copper sulfate 3 MG / dl-alpha tocopheryl acetate 30 UNT / docusate sodium 50 MG / folic acid 1 MG / iron carbonyl 150 MG / vitamin B12 0.06 MG Extended Release Oral Tablet [Hemax]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "204602", "drug_name": "bacitracin 0.4 UNT/MG / neomycin 0.0035 MG/MG / polymyxin B 5 UNT/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "433733", "drug_name": "esomeprazole 20 MG Delayed Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1011852", "drug_name": "lidocaine hydrochloride 0.02 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1858984", "drug_name": "lidocaine hydrochloride 0.04 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2462510", "drug_name": "hydrocortisone 0.01 MG/MG Topical Ointment [Aquaphor Itch Relief]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1421893", "drug_name": "lidocaine 40 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "646333", "drug_name": "capsaicin 1 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2559400", "drug_name": "lidocaine 0.04 MG/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2677085", "drug_name": "undecylenic acid 130 MG/ML Topical Cream [Tripenicol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2679333", "drug_name": "tolnaftate 10 MG/ML Topical Solution [Tritolnacide]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "2562183", "drug_name": "lidocaine hydrochloride 0.028 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "NON-PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "404448", "drug_name": "84 HR oxybutynin 0.162 MG/HR Transdermal System [Oxytrol]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1046266", "drug_name": "naphazoline hydrochloride 0.25 MG/ML / pheniramine maleate 3 MG/ML Ophthalmic Solution [Naphcon A]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198029", "drug_name": "24 HR nicotine 0.583 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198030", "drug_name": "24 HR nicotine 0.875 MG/HR Transdermal System", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "314119", "drug_name": "nicotine 2 MG Chewing Gum", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "311975", "drug_name": "nicotine 4 MG Chewing Gum", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "204442", "drug_name": "ibuprofen 40 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "204602", "drug_name": "bacitracin 0.4 UNT/MG / neomycin 0.0035 MG/MG / polymyxin B 5 UNT/MG Topical Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "318146", "drug_name": "fructose 374 MG/ML / glucose 374 MG/ML / phosphoric acid 4.3 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "351261", "drug_name": "lansoprazole 15 MG Disintegrating Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "596843", "drug_name": "lansoprazole 15 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "199047", "drug_name": "famotidine 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "197803", "drug_name": "ibuprofen 20 MG/ML Oral Suspension", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310273", "drug_name": "famotidine 20 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "998540", "drug_name": "miconazole nitrate 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "855172", "drug_name": "levocetirizine dihydrochloride 5 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "310964", "drug_name": "ibuprofen 200 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "359817", "drug_name": "nicotine 2 MG Oral Lozenge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "198380", "drug_name": "tioconazole 0.065 MG/MG Vaginal Ointment", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "310965", "drug_name": "ibuprofen 200 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "106258", "drug_name": "hydrocortisone 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "692783", "drug_name": "loratadine 1 MG/ML Oral Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "997420", "drug_name": "fexofenadine hydrochloride 180 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "283219", "drug_name": "piperonyl butoxide 40 MG/ML / pyrethrins 3.3 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "359818", "drug_name": "nicotine 4 MG Oral Lozenge", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "606726", "drug_name": "esomeprazole 20 MG Delayed Release Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "849574", "drug_name": "naproxen sodium 220 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "855633", "drug_name": "diclofenac sodium 0.01 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "250387", "drug_name": "permethrin 10 MG/ML Medicated Shampoo", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1242399", "drug_name": "12 HR loratadine 5 MG / pseudoephedrine sulfate 120 MG Extended Release Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "2676107", "drug_name": "{28 (norgestrel 0.075 MG Oral Tablet) } Pack [Opill 28 Day]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1014678", "drug_name": "cetirizine hydrochloride 10 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "1737778", "drug_name": "lidocaine 0.04 MG/MG Medicated Patch", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "644386", "drug_name": "ibuprofen 200 MG Oral Capsule [Wal-Profen]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { 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false, "years": [ 2027 ] } ] }, { "rxnorm_id": "900038", "drug_name": "phentermine hydrochloride 30 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "968766", "drug_name": "phentermine hydrochloride 15 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "308694", "drug_name": "benzoyl peroxide 0.05 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "486131", "drug_name": "benzoyl peroxide 0.1 MG/MG Topical Gel", "plans": [ { "plan_id_type": "PLAN-ID", 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"prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1422080", "drug_name": "lidocaine 40 MG/ML Topical Cream [AneCream]", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "199603", "drug_name": "clotrimazole 20 MG/ML Vaginal Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "198707", "drug_name": "hydrocortisone 5 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992528", "drug_name": "terbinafine hydrochloride 10 MG/ML Topical Cream", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "992766", "drug_name": "{1 (9000 MG) (miconazole nitrate 20 MG/ML Vaginal Cream) / 3 (miconazole nitrate 200 MG Vaginal Insert) } Pack", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "995666", "drug_name": "meclizine hydrochloride 25 MG Oral Tablet", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1543313", "drug_name": "clotrimazole 0.01 MG/MG Topical Ointment [Alevazol]", "plans": [ { "plan_id_type": 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"step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1111339", "drug_name": "olopatadine 1 MG/ML Ophthalmic Solution", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "705934", "drug_name": "tolnaftate 0.01 MG/MG Powder Spray", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "years": [ 2027 ] } ] }, { "rxnorm_id": "1112231", "drug_name": "naproxen sodium 220 MG Oral Capsule", "plans": [ { "plan_id_type": "PLAN-ID", "plan_id": "AHCPAWRAP", "drug_tier": "PREFERRED-BRAND", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "years": [ 2027 ] } ] }, { "rxnorm_id": "665078", "drug_name": "loratadine 5 MG Chewable Tablet", "plans": [ { 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