Page 70 - Cover Letter and Evaluation for Barbara Lesswing

11/20/2017 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.
Estradiol DIS 0.05MG (Twice Weekly Patch) Estradiol DIS 0.05MG (Twice Weekly Patch)
Prior Authorization Prior Authorization

Tier 2: Generic Quantity Limit
Januvia TAB 100MG
Tier 3: Preferred Brand
No restrictions Januvia TAB 100MG

Tier 3: Preferred Brand Quantity Limit
Levothyroxine Sodium TAB 112MCG Tier 3: Preferred Brand
No restrictions Levothyroxine Sodium TAB 112MCG
No restrictions
Tier 2: Generic
Lisinopril TAB 20MG Tier 1: Preferred Generic
No restrictions Lisinopril TAB 20MG
No restrictions
Tier 1: Preferred Generic
Metformin Hcl TAB 500MG ER Tier 1: Preferred Generic
Metformin Hcl TAB 500MG ER
No restrictions
No restrictions
Tier 1: Preferred Generic
Pantoprazole Sodium TAB 40MG Tier 2: Generic
Pantoprazole Sodium TAB 40MG
No restrictions
Quantity Limit
Tier 2: Generic
Tier 1: Preferred Generic

Print My Drug List Print Comparison Report

Pharmacy & Mail Order Information

Mail Order is available. Mail Order is available.
Pharmacy Network Pharmacy Network
4 network pharmacies in your ZIP code 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 Add
ESTRADIOL DIS 0.05MG (TWICE 1 X 1 Box of 8 Every 1 Month Already Generic Remove
WEEKLY PATCH) patches Retail Pharmacy

Change dose Add
JANUVIA TAB 100MG 30 Every 1 Month Generic Not Available Remove
Retail Pharmacy

Change dose Add
LEVOTHYROXINE SODIUM TAB 30 Every 1 Month Already Generic Remove
112MCG Retail Pharmacy

LISINOPRIL TAB 20MG 30 Every 1 Month Already Generic Change dose Add
Retail Pharmacy
Remove
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