Page 88 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details
Restrictions
Restrictions
PRIOR
QUANTITY
SELECTED DRUGS TIER PRIOR QUANTITY STEP
TIER
STEP
SELECTED DRUGS
(FORMULARY AUTHORIZATION LIMITS [?] THERAPY
(FORMULARY
LIMITS [?]
THERAPY
AUTHORIZATION
STATUS) [?] [?] [?]
[?]
[?]
STATUS) [?]
Carvedilol TAB 25MG Tier 1: Preferred
Generic
Diltiazem Hcl Sr CAP 240MG/24 Tier 3: Preferred Brand
Metformin Hcl TAB 1000MG Tier 1: Preferred
Yes
Generic
Multaq TAB 400MG Tier 3: Preferred Brand Yes
Olmesartan Medoxomil/Hydrochlorothiazide TAB Yes
40-12.5 Tier 2: Generic
Omega-3-Acid Ethyl Esters CAP 1GM Tier 4: Non-Preferred
Yes
Drug
Potassium Chloride Cr (Microencapsulated) TAB
10MEQ CR Tier 2: Generic
Pravastatin Sodium TAB 10MG Tier 1: Preferred
Yes
Generic
Print My Drug List Print Plan Report View Drug Benefit Summary
Pharmacy & Mail Order Information
Mail Order is available.
Pharmacy Network [?]
4 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
OLMESARTAN
MEDOXOMIL/HYDROCHLOROTHIAZIDE TAB 30 Every 1 Month Already Generic Change dose
40-12.5 Retail (You originally Add Remove
Pharmacy entered Benicar HCT)
Switch Back
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