Page 64 - Appendices for Rick Leininger
P. 64
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Metoprolol tartrate 37.5mg tablet
1
Tier
Pravastatin sodium 10mg tablet Yes
1
Tamsulosin hydrochloride 0.4mg Tier
capsule 2
Tier
Xarelto 20mg tablet
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
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