Page 59 - APPENDICES for Stephen Spero
P. 59
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Atorvastatin 10mg tablet
6
Tier
Januvia 100mg tablet Yes
3
Tier
Lisinopril 10mg tablet
6
Metformin hcl er (osm) 1000mg tablet Tier
Yes
extended release 24 hour 4
Tier
Temazepam 15mg capsule Yes
2
MY DRUG LIST
Selected drugs Package Quantity Frequency Brand/Generic
Every
Atorvastatin 10mg tablet 30 Generic
month
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