Page 32 - Evaluation for John Shartle

11/3/2017 Your Medicare Health Plan Comparison
All of your drugs are covered on the plan’s formulary. All of your drugs are covered on the plan’s formulary.
Anoro Ellipta AER 62.5-25 Anoro Ellipta AER 62.5-25
Quantity Limit Quantity Limit

Tier 3: Preferred Brand Tier 3: Preferred Brand
Atorvastatin Calcium TAB 10MG Atorvastatin Calcium TAB 10MG
No restrictions Quantity Limit

Tier 1: Preferred Generic Tier 1: Preferred Generic
Eliquis TAB 5MG Eliquis TAB 5MG
No restrictions No restrictions
Tier 3: Preferred Brand Tier 3: Preferred Brand
Lisinopril/Hctz TAB 20-12.5 Lisinopril/Hctz TAB 20-12.5
No restrictions No restrictions

Tier 1: Preferred Generic Tier 1: Preferred Generic

Print My Drug List Print Comparison Report

Pharmacy & Mail Order Information

Mail Order is available. Mail Order is available.
Pharmacy Network Pharmacy Network
2 network pharmacies in your ZIP code 2 network pharmacies in your ZIP code
Preferred pharmacy network available Preferred pharmacy network available

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY

Change dose Add
ANORO ELLIPTA AER 62.5-25 1 X 1 Blister Every 2 Months Generic Not Available Remove
Pack of 60 Retail Pharmacy
aerosols

Change dose Add
ATORVASTATIN CALCIUM TAB 30 Every 1 Month Already Generic Remove
10MG Retail Pharmacy

Change dose Add
ELIQUIS TAB 5MG 60 Every 1 Month Generic Not Available Remove
Retail Pharmacy

Change dose Add
LISINOPRIL/HCTZ TAB 20-12.5 30 Every 1 Month Already Generic Remove
Retail Pharmacy

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