Page 54 - APPENDICES for Vic Bosiger
P. 54

Prior                   Quantity         Step
                                                        Tier
                                                                   authorization           limits           therapy




       Nitroglycerin 0.4mg tablet                       Tier
       sublingual                                       2          —                       —                —





       Omeprazole 20mg capsule                          Tier
       delayed release                                  1          —                       Yes              —






                                                        Tier
       Prasugrel 10mg tablet                                       —                       —                —
                                                        2




                                                        Tier
       Rosuvastatin calcium 40mg tablet                            —                       —                —
                                                        1




       Victoza 18mg/3ml solution pen                    Tier

       injector                                         3          —                       Yes              —
   49   50   51   52   53   54   55   56   57   58   59