Page 72 - APPENDICES for Janet Tuma

OTHER DRUG INFORMATION

Selected drugs Tier Prior Quantity Step
authorization limits therapy

Diltiazem hydrochloride 300mg capsule Tier
Yes
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

Every
Hydrochlorothiazide 25mg tablet 30 Generic
month

Edit/Remove drugs

PART B DRUGS