Page 97 - Appendices to Donald Pender's Evaluation

Initial coverage Gap coverage Catastrophic coverage
phase phase phase

Generic drugs:
Generic drugs:
25% $3.95 copay or 5% (whichever
costs more)
Specialty Tier 25%
Brand-name Brand-name drugs:
drugs: $9.85 copay or 5% (whichever
25%
costs more)

OTHER DRUG INFORMATION

Prior Quantity Step
Tier
authorization limits therapy

Dutasteride 0.5mg Tier

capsule 3 — Yes —

MY DRUG LIST

Package Quantity Frequency Brand/Generic

Dutasteride 0.5mg Every
capsule 30 month Generic

PART B DRUGS

These are drugs you usually get at a doctor's o ce or hospital outpatient setting, like the u shot,

chemotherapy, or other shots.

Chemotherapy drugs Not covered

Other Part B drugs Not covered