Page 90 - 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 [?]
Metoprolol Tartrate TAB 25MG
Tier 1: Preferred Generic
Nitroglycerin SUB 0.4MG
Tier 3: Preferred Brand
Omeprazole CAP 20MG
Tier 2: Generic
Sertraline Hcl TAB 100MG
Tier 1: Preferred Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
12 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

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