Page 78 - APPENDICES for Stephen Spero
P. 78

Selected drugs                                Package        Quantity        Frequency         Brand/Generic



                                                                                   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




      Edit/Remove drugs












      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






         Drug plan (Part D) star rating
   73   74   75   76   77   78   79   80   81   82   83