Page 78 - APPENDICES for Neill McLauchlin
P. 78
Time period Estimated monthly drug costs
October $151.26
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Lisinopril 40mg tablet
1
Tier
Methimazole 5mg tablet
1
Propranolol hydrochloride 120mg capsule Tier
extended release 24 hour 3
Tolterodine tartrate 4mg capsule extended Tier
Yes Yes
release 24 hour 4
MY DRUG LIST
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