Page 36 - Rx Drug Plan review for John

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Carvedilol 25mg tablet Tier 2 — — —

Diltiazem hydrochloride 240mg
capsule extended release 24 Tier 3 — — —
hour

Febuxostat 40mg tablet Tier 3 — — Yes

Hydrochlorothiazide 50mg
tablet Tier 1 — — —

Metformin hydrochloride
1000mg tablet Tier 1 — Yes —

Multaq 400mg tablet Tier 3 — Yes —

Olmesartan medoxomil 40mg

tablet Tier 3 — Yes —

Omega-3 acid ethyl esters (usp)
1gm capsule Tier 4 — Yes —

Potassium chloride 10meq Not
capsule extended release covered — — —

Pravastatin sodium 10mg tablet Tier 2 — Yes —