Page 104 - APPENDICES for Fred Falten
P. 104
Time period Estimated monthly drug costs
October $12.00
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Amlodipine 2.5mg tablet
1
Tier
Atorvastatin 20mg tablet
1
Metoprolol succinate 50mg tablet extended Tier
release 24 hour 2
Tier
Tamsulosin hydrochloride 0.4mg capsule
2
MY DRUG LIST
Selected drugs Package Quantity Frequency Brand/Generic
Edit/Remove drugs
