Page 73 - APPENDICES for Fred Falten

MY DRUG LIST

Selected drugs Package Quantity Frequency Brand/Generic

Every
Amlodipine 2.5mg tablet 30 Generic
month

Every
Atorvastatin 20mg tablet 30 Generic
month

Metoprolol succinate 50mg tablet Every
30 Generic
extended release 24 hour month

Tamsulosin hydrochloride 0.4mg Every
60 Generic
capsule month

Edit/Remove drugs

PART B DRUGS

Chemotherapy drugs
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Limits apply

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Limits apply