Page 77 - APPENDICES for Vic Bosiger

Prior Quantity Step
Tier
authorization limits therapy

Nitroglycerin 0.4mg tablet Tier
sublingual 3 — — —

Omeprazole 20mg capsule Tier
delayed release 1 — Yes —

Tier
Prasugrel 10mg tablet — Yes —
4

Tier
Rosuvastatin calcium 40mg tablet — — —
1

Victoza 18mg/3ml solution pen Tier

injector 3 — Yes —