Page 96 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Comparison
All of your drugs are covered on the plan’s formulary. All of your drugs are covered on the plan’s formulary.
Atorvastatin Calcium TAB 40MG Atorvastatin Calcium TAB 40MG
Quantity Limit Quantity Limit

Tier 1: Preferred Generic 7 Tier 1: Preferred Generic 7
Brilinta TAB 90MG Brilinta TAB 90MG
No restrictions No restrictions

Tier 3: Preferred Brand Tier 3: Preferred Brand
Lisinopril TAB 2.5MG Lisinopril TAB 2.5MG
No restrictions No restrictions
Tier 1: Preferred Generic 7 Tier 1: Preferred Generic 7
Metoprolol Tartrate TAB 25MG Metoprolol Tartrate TAB 25MG
No restrictions No restrictions

Tier 1: Preferred Generic 7 Tier 1: Preferred Generic 7
Nitroglycerin SUB 0.4MG Nitroglycerin SUB 0.4MG
No restrictions No restrictions

Tier 4: Non-Preferred Drug Tier 4: Non-Preferred Drug
Omeprazole CAP 20MG Omeprazole CAP 20MG

Quantity Limit Quantity Limit
Tier 1: Preferred Generic 7 Tier 1: Preferred Generic 7
Sertraline Hcl TAB 100MG Sertraline Hcl TAB 100MG
Quantity Limit Quantity Limit
Tier 1: Preferred Generic 7 Tier 1: Preferred Generic 7

Print My Drug List Print Comparison Report
7 The price displayed for this drug may be lower than what you would typically pay during this period because of
additional gap coverage offered by this plan.

Pharmacy & Mail Order Information

Mail Order is available. Mail Order is available.
Pharmacy Network Pharmacy Network
13 network pharmacies in your ZIP code 13 network pharmacies in your ZIP code
Preferred pharmacy network available Preferred pharmacy network available

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY

Change dose Add
ATORVASTATIN CALCIUM TAB 30 Every 1 Month Already Generic Remove
40MG Retail Pharmacy

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

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