Page 140 - Cover Letter and Evaluation for Gary Janke

10/8/2018 Your Medicare Health Plan Details
SELECTED DRUGS TIER PRIOR QUANTITY STEP
Restrictions
(FORMULARY STATUS) AUTHORIZATION LIMITS THERAPY
[?] [?] [?] [?]
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) AUTHORIZATION LIMITS THERAPY
[?] [?] [?] [?]
Amlodipine Besylate TAB 5MG
Tier 1: Preferred Generic
Budesonide Suspension SUS 0.5MG/2 Tier 4: Non-Preferred
Yes
Drug
Omeprazole CAP 40MG
Tier 1: Preferred Generic
Potassium Chloride CAP 10MEQ CR
Tier 3: Preferred Brand
Ranitidine Hcl TAB 300MG
Tier 1: Preferred Generic
Symbicort AER 160-4.5
Tier 3: Preferred Brand Yes
Valsartan/Hydrochlorothiazide TAB 160-
12.5 Tier 1: Preferred Generic
Ventolin HFA AER
Tier 3: Preferred Brand Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
13 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List
Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY
Change dose Add
AMLODIPINE BESYLATE TAB 5MG 30 Every 1 Month Already Generic Remove
Retail
Pharmacy

Change dose Add
BUDESONIDE SUSPENSION SUS 0.5MG/2 1 X 2ML Every 1 Month Already Generic Remove
Plastic Retail
Container Pharmacy
(sold in a
package of 30
plastic
containers)

Change dose Add

OMEPRAZOLE CAP 40MG 60 Every 1 Month Already Generic Remove
Retail
Pharmacy

Change dose Add

POTASSIUM CHLORIDE CAP 10MEQ CR 30 Every 1 Month Already Generic Remove
Retail
Pharmacy

RANITIDINE HCL TAB 300MG
60 Every 1 Month Already Generic Change dose Add
Retail Remove
Pharmacy
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