Page 58 - Appendices for Eric Hartman
P. 58

OTHER DRUG INFORMATION




                                                             Prior                   Quantity             Step
                                                 Tier
                                                             authorization           limits               therapy





                                                 Tier
       Atorvastatin 10mg tablet                              —                       —                    —
                                                 1





                                                 Tier
       Finasteride 5mg tablet                                —                       —                    —
                                                 1





       Levothyroxine sodium                      Tier
       25mcg tablet                              1           —                       —                    —





                                                 Tier
       Terazosin 2mg capsule                                 —                       —                    —
                                                 1
   53   54   55   56   57   58   59   60   61   62   63