Page 107 - Appendices to Heidi Bathon's Evaluation

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Tier
Alprazolam 0.25mg tablet — Yes —
2

Creon 6000-19000unit capsule delayed release Tier
particles 3 — — —

Tier
Diclofenac epolamine 1.3% patch Yes Yes —
4

Duloxetine 60mg capsule delayed release Tier
particles 2 — Yes —

Tier
Estradiol 0.1mg/gm cream — — —
3

Tier
Levothyroxine sodium 50mcg tablet — — —
1

Tier
Mirtazapine 45mg tablet — — —
2

Tier
Omeprazole 20mg capsule delayed release — — —
2

Tier
Rosuvastatin calcium 5mg tablet — Yes —
2

Tier
Triamcinolone acetonide 0.1% cream — — —
2