Page 53 - APPENDICES for Vic Bosiger

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Tier
Alprazolam 0.5mg tablet — Yes —
1

Tier
Amlodipine 5mg tablet — — —
1

Tier
Carvedilol 25mg tablet — — —
1

Tier
Farxiga 10mg tablet — — —
3

Tier
Furosemide 40mg tablet — — —
1

Tier
Glipizide 10mg tablet — — —
1

Isosorbide mononitrate 30mg Tier
tablet extended release 24 hour 1 — — —

Tier
Lisinopril 20mg tablet — — —
1

Metformin hydrochloride 1000mg Tier
tablet 1 — — —