Page 120 - Cover Letter and Evaluation for Anne Ellzey

11/8/2017 Your Medicare Health Plan Details

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) AUTHORIZATION LIMITS THERAPY
[?] [?] [?] [?]
Alprazolam TAB 0.25MG
Tier 2: Generic Yes
Aripiprazole TAB 15MG Tier 4: Non-Preferred
Yes
Drug
Cyclobenzaprine Hcl TAB 5MG
Tier 3: Preferred Brand Yes Yes
Exemestane TAB 25MG Tier 4: Non-Preferred
Drug
Hydrocodone/Acetaminophen TAB 5- 13 Yes
300MG Tier 3: Preferred Brand
Lamotrigine TAB 150MG
Tier 2: Generic
Losartan Potassium TAB 25MG
Tier 1: Preferred Generic Yes
Lyrica CAP 50MG
Tier 3: Preferred Brand Yes
Meloxicam TAB 7.5MG
Tier 1: Preferred Generic
Sumatriptan SPR 20MG/ACT
Tier 2: Generic Yes
Venlafaxine Hcl TAB 150MG ER
Tier 3: Preferred Brand Yes
Zolpidem Tartrate TAB 10MG
Tier 2: Generic Yes Yes
Print My Drug List Print Plan Report View Drug Benefit Summary
13 Opioid pain medications are subject to additional safety review.

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
10 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
ALPRAZOLAM TAB 0.25MG 60 Every 2 Months Already Generic Remove
Retail
Pharmacy

Change dose Add
ARIPIPRAZOLE TAB 15MG 30 Every 2 Months Already Generic Remove
Retail
Pharmacy

Change dose Add
CYCLOBENZAPRINE HCL TAB 5MG 90 Every 2 Months Already Generic Remove
Retail
Pharmacy

EXEMESTANE TAB 25MG
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5810&plnid=056&sgmntid=0 3/4