Page 74 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY AUTHORIZATION LIMITS THERAPY
STATUS) [?] [?] [?] [?]
Bupropion Hcl TAB 300MG XL
Tier 3: Preferred Brand Yes
Finasteride (5Mg) TAB 5MG Tier 1: Preferred
Yes
Generic
Losartan Potassium/Hydrochlorothiazide Tier 1: Preferred
TAB 100-25 Yes
Generic
Metoprolol Succinate Er TAB 25MG ER
Tier 2: Generic
Omeprazole CAP 40MG Tier 1: Preferred
Yes
Generic
Proair HFA AER 15
Not on Formulary
Tamsulosin Hcl CAP 0.4MG
Tier 2: Generic Yes
Trazodone Hcl TAB 50MG
Tier 2: Generic
Truvada TAB
Tier 5: Specialty Tier Yes
Print My Drug List Print Plan Report View Drug Benefit Summary
15 Any amount you spend for a non-formulary drug is not counted towards the deductible, initial coverage limit or out-of-pocket costs UNLESS the plan approves a
formulary exception. If an exception is approved, the non-formulary drug will be covered at Tier 4. The drug cost displayed is only an estimate and actual cost may
vary. Please contact the plan for more information.
Pharmacy & Mail Order Information

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

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
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0#plan_drug_cost 3/4