Page 64 - APPENDICES for Neill McLauchlin

MY DRUG LIST

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
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Limits apply

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Limits apply

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