Page 121 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY AUTHORIZATION LIMITS [?] THERAPY
STATUS) [?] [?] [?]
Carvedilol TAB 25MG Tier 1: Preferred

Generic
Diltiazem Hcl Sr CAP 240MG/24
Tier 2: Generic
Metformin Hcl TAB 1000MG Tier 1: Preferred

Generic
Multaq TAB 400MG Tier 4: Non-Preferred

Drug
Olmesartan Medoxomil/Hydrochlorothiazide TAB Tier 4: Non-Preferred
40-12.5 Yes
Drug
Omega-3-Acid Ethyl Esters CAP 1GM Tier 4: Non-Preferred
Drug Yes
Potassium Chloride Cr (Microencapsulated) TAB
10MEQ CR Tier 2: Generic
Pravastatin Sodium TAB 10MG Tier 1: Preferred
Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
6 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
CARVEDILOL TAB 25MG 120 Every 1 Month Already Generic Add Remove
Retail
Pharmacy

Change dose
DILTIAZEM HCL SR CAP 240MG/24 30 Every 1 Month Already Generic Add Remove
Retail (You originally
Pharmacy entered Cardizem
CD) Switch Back

Change dose
METFORMIN HCL TAB 1000MG 60 Every 1 Month Already Generic Add Remove
Retail
Pharmacy

Change dose
MULTAQ TAB 400MG 60 Every 1 Month Generic Not Available Add Remove
Retail
Pharmacy

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=126&sgmntid=0#plan_drug_cost 3/4