Page 89 - APPENDICES for Fred Falten

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
Yes
release 24 hour 1

Tier
Tamsulosin hydrochloride 0.4mg capsule
2

MY DRUG LIST

Selected drugs Package Quantity Frequency Brand/Generic

Every
Amlodipine 2.5mg tablet 30 Generic
month

Every
Atorvastatin 20mg tablet 30 Generic
month

Metoprolol succinate 50mg tablet Every
30 Generic
extended release 24 hour month

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