Page 97 - APPENDICES for Stephen Spero

Selected drugs Tier Prior Quantity Step
authorization limits therapy

Tier
Atorvastatin 10mg tablet Yes
1

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

Every
Januvia 100mg tablet 30 Brand
month

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