Page 60 - APPENDICES for Stephen Spero

Selected drugs Package Quantity Frequency Brand/Generic

Every
Januvia 100mg tablet 30 Brand
month

Every
Lisinopril 10mg tablet 30 Generic
month

Metformin hcl er (osm) 1000mg Every
30 Generic
tablet extended release 24 hour month

Every 2
Temazepam 15mg capsule 30 Generic
months

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PART B DRUGS

Chemotherapy drugs
20% coinsurance

Limits apply

Other Part B drugs
20% coinsurance

Limits apply

Star ratings

OVERALL STAR RATING

Health plan star ratings