Page 39 - APPENDICES for Janet Tuma
P. 39
Time period Estimated monthly drug costs
June $4.20
September $4.20
December $4.20
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Diltiazem hydrochloride 300mg capsule Tier
extended release 24 hour 2
Tier
Hydrochlorothiazide 25mg tablet
1
MY DRUG LIST
Selected drugs Package Quantity Frequency Brand/Generic
Diltiazem hydrochloride 300mg Every
30 Generic
capsule extended release 24 hour month
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