Page 45 - APPENDICES for Diane Falten
P. 45

OTHER DRUG INFORMATION




                                                                 Prior                  Quantity           Step
                                                     Tier
                                                                 authorization          limits             therapy





                                                     Tier
       Amlodipine 5mg tablet                                     —                      —                  —
                                                     1





                                                     Tier
       Atorvastatin 20mg tablet                                  —                      Yes                —
                                                     1





       Losartan potassium 100mg                      Tier
       tablet                                        1           —                      —                  —





       Memantine hydrochloride 5mg                   Tier
       tablet                                        2           Yes                    —                  —





       Metformin hydrochloride                       Tier
       1000mg tablet                                 1           —                      Yes                —





       Omeprazole 40mg capsule                       Tier
       delayed release                               1           —                      —                  —





       Trazodone hydrochloride 50mg                  Tier
       tablet                                        1           —                      —                  —
   40   41   42   43   44   45   46   47   48   49   50