Page 56 - Appendices for Rick Leininger
P. 56
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Metoprolol tartrate 37.5mg tablet
1
Tier
Pravastatin sodium 10mg tablet
1
Tamsulosin hydrochloride 0.4mg Tier
capsule 2
Tier
Xarelto 20mg tablet Yes
3
MY DRUG LIST
Selected drugs Package Quantity Frequency Brand/Generic
Every
Metoprolol tartrate 37.5mg tablet 60 Generic
month
Every
Pravastatin sodium 10mg tablet 30 Generic
month
Tamsulosin hydrochloride 0.4mg Every
60 Generic
capsule month
Edit/Remove drugs
