Page 72 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details
Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Lorazepam TAB 0.5MG
Tier 2: Generic Yes
Losartan Potassium TAB 50MG
Tier 1: Preferred Generic Yes
Nabumetone TAB 500MG
Tier 2: Generic
Propranolol Hcl TAB 10MG
Tier 2: Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
10 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List
Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY
Change dose Add
AMLODIPINE BESYLATE TAB 10MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
LORAZEPAM TAB 0.5MG 60 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
LOSARTAN POTASSIUM TAB 50MG 60 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
NABUMETONE TAB 500MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
PROPRANOLOL HCL TAB 10MG 60 Every 1 Month Already Generic Remove
Retail Pharmacy

Return to previous page

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=150&sgmntid=0#plan_drug_cost 3/3