Page 40 - APPENDICES for Janet Tuma

Selected drugs Package Quantity Frequency Brand/Generic

Every
Hydrochlorothiazide 25mg tablet 30 Generic
month

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PART B DRUGS

Chemotherapy drugs
In-network: 20% coinsurance

Out-of-network: 50% coinsurance

Limits apply

Other Part B drugs
In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Limits apply

Star ratings

OVERALL STAR RATING

HEALTH PLAN STAR RATINGS

DRUG PLAN (PART D) STAR RATING

Contact information