Page 81 - Appendices for Eric Hartman

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Tier
Atorvastatin 10mg tablet — Yes —
6

Tier
Finasteride 5mg tablet — Yes —
1

Levothyroxine sodium Tier
25mcg tablet 1 — — —

Tier
Terazosin 2mg capsule — Yes —
1