Page 100 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Details
Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Brilinta TAB 90MG
Tier 3: Preferred Brand
Lisinopril TAB 2.5MG
Tier 1: Preferred Generic
Metoprolol Tartrate TAB 25MG
Tier 1: Preferred Generic
Nitroglycerin SUB 0.4MG
Tier 4: Non-Preferred Drug
Omeprazole CAP 20MG
Tier 1: Preferred Generic Yes
Sertraline Hcl TAB 100MG
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 [?]
13 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 Add
ATORVASTATIN CALCIUM TAB 40MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
BRILINTA TAB 90MG 60 Every 1 Month Generic Not Available Remove
Retail Pharmacy

Change dose Add
LISINOPRIL TAB 2.5MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
METOPROLOL TARTRATE TAB 25MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
NITROGLYCERIN SUB 0.4MG 20 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add

OMEPRAZOLE CAP 20MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
SERTRALINE HCL TAB 100MG 30 Every 2 Months Already Generic Remove
Retail Pharmacy

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3931&plnid=126&sgmntid=0#plan_drug_cost 3/4