Premera My Medication List


Physicians and providers: Review this list and
My medication list
instruct the patient on any changes you make.
Name _______________________________________________________________________________________
Physician Name ___________________________________________ Phone ____________________________
Here’s how to find out if your particular combination of medications are safe:
1. List all your medications below, including over-the-counter medicines, vitamins and
herbal supplements.
2. Review your medication list once a year with your healthcare provider.
3. Ask your doctor to explain each medicine:
• Why you are taking it
• How long you can expect to take it
• Describe any possible side effects.
Name of Medicine
Directions for use
Why taking it?
0.05 mg
Once daily for 90 days.
Provided by Premera Blue Cross and Premera Blue Cross Blue Shield of Alaska, an Independent Licensee of the Blue Cross Blue Shield Association.
012998 (11-2008)


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