Page 44 - Memo to Michael Boucher
P. 44
Time period Estimated monthly drug costs
October $658.76
November $658.76
December $658.76
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Flecainide acetate 50mg tablet
2
Praluent 75mg/ml solution auto Tier Yes
injector 1 3
1 This drug may only be available at certain pharmacies due to reasons such as special handling or
requirements by the Food and Drug Administration. Please contact the plan for details.
MY DRUG LIST
Selected drugs Package Quantity Frequency Brand/Generic
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