Page 104 - Appendices for Eric Hartman

Initial coverage Gap coverage
phase phase Catastrophic coverage phase

Generic drugs:
Generic drugs:
25% $4.15 copay or 5% (whichever
costs more)
Specialty Tier 25%
Brand-name Brand-name drugs:
drugs: $10.35 copay or 5% (whichever
25%
costs more)

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Tier
Atorvastatin 10mg tablet — Yes —
1

Tier
Finasteride 5mg tablet — Yes —
1

Levothyroxine sodium Tier

25mcg tablet 1 — — —

Tier
Terazosin 2mg capsule — — —
1