Page 48 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY AUTHORIZATION LIMITS THERAPY
STATUS) [?] [?] [?] [?]
Bupropion Hcl TAB 300MG XL
Tier 2: Generic
Finasteride (5Mg) TAB 5MG Tier 1: Preferred
Generic
Losartan Potassium/Hydrochlorothiazide Tier 1: Preferred
TAB 100-25 Yes
Generic
Metoprolol Succinate Er TAB 25MG ER Tier 1: Preferred
Generic
Omeprazole CAP 40MG
Tier 2: Generic Yes
Proair HFA AER
Tier 3: Preferred Brand
Tamsulosin Hcl CAP 0.4MG Tier 1: Preferred

Generic
Trazodone Hcl TAB 50MG Tier 1: Preferred

Generic
Truvada TAB
Tier 5: Specialty Tier Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
6 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY
Change dose Add
BUPROPION HCL TAB 300MG XL 30 Every 1 Month Already Generic Remove
Retail
Pharmacy

Change dose Add
FINASTERIDE (5MG) TAB 5MG 30 Every 1 Month Already Generic Remove
Retail
Pharmacy

Change dose Add
LOSARTAN 30 Every 1 Month Already Generic Remove
POTASSIUM/HYDROCHLOROTHIAZIDE TAB
100-25 Retail
Pharmacy

Change dose Add
METOPROLOL SUCCINATE ER TAB 25MG ER 30 Every 1 Month Already Generic Remove
Retail
Pharmacy

OMEPRAZOLE CAP 40MG
30 Every 1 Month Already Generic Change dose Add
Retail Remove
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H0609&plnid=028&sgmntid=0#plan_drug_cost 3/4