Page 82 - Appendices for Eric Hartman
P. 82
MY DRUG LIST
Package Quantity Frequency Brand/Generic
Every 2
Atorvastatin 10mg tablet 30 Generic
months
Every
Finasteride 5mg tablet 30 Generic
month
Levothyroxine sodium Every
25mcg tablet 30 month Generic
Every
Terazosin 2mg capsule 60 Generic
month
PART B DRUGS
These are drugs you usually get at a doctor's o ce or hospital outpatient setting, like the u shot,
chemotherapy, or other shots.
Chemotherapy drugs In-network: 20% coinsurance Limits apply
Out-of-network: 30%
coinsurance
Other Part B drugs In-network: 20% coinsurance Limits apply
Out-of-network: 30%
coinsurance
Extra Bene ts
