Page 47 - APPENDICES for Neill McLauchlin
P. 47

Selected drugs                                Package        Quantity        Frequency         Brand/Generic



                                                                                   Every
      Lisinopril 40mg tablet                                       30                                Generic
                                                                                   month



                                                                                   Every
      Methimazole 5mg tablet                                       15                                Generic
                                                                                   month



      Propranolol hydrochloride 120mg                                              Every
                                                                   30                                Generic
      capsule extended release 24 hour                                             month




      Tolterodine tartrate 4mg capsule                                             Every
                                                                   30                                Generic
      extended release 24 hour                                                     month




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      PART B DRUGS



      Chemotherapy drugs
      20% coinsurance

      Limits apply



      Other Part B drugs
      20% coinsurance

      Limits apply







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