Page 52 - Cover Letter and Appendices for Melanie April 2019

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CVS Pharmacy #05380 Walgreens #9908 Mail Order Pharmacy

CVS Pharmacy #05380 - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Clindamycin
1%/Benzoyl Peroxide $173.28 Every 2 $173.28 $173.28 $64.11 $8.66
Months
5% GEL 1-5% 16
Diazepam TAB 2MG Every 3
$8.69 $8.69 $8.69 $3.22 $3.40
Months
Digoxin TAB 0.25MG Every 1
$16.66 $4.00 $4.00 $6.16 $3.40
Month
Fluoxetine Hcl CAP Every 1
$7.70 $1.00 $1.00 $2.85 $3.40
20MG Month
Fluticasone Propionate Every 1
$7.24 $4.00 $4.00 $2.68 $3.40
Nasal SPR 50MCG Month
Metronidazole Topical Every 3
$126.62 $12.00 $12.00 $46.85 $6.33
GEL 1% Months
Tramadol Hcl TAB Every 3
50MG $30.51 Months $12.00 $12.00 $11.29 $3.40
Warfarin Sodium TAB Every 1
$10.88 $1.00 $1.00 $4.03 $3.40
6MG Month
MONTHLY TOTALS: $381.58 $215.97 $215.97 $141.19 $35.39

16 This drug is covered by the plan; however, the plan does not offer a benefit for the frequency and pharmacy type you selected. Therefore, the cost displayed
is an estimate of the full cost of the drug for the frequency entered.
Estimated Monthly Drug Costs

CVS Pharmacy #05380 Walgreens #9908 Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A N/A N/A N/A $240 $34 $207 $67 $207 $34 $240 $34

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Graph depicts an estimate of your monthly prescription drug costs, including any applicable premium for this plan.
Actual costs may vary.
View a more detailed explanation of these costs.
Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription
drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its
coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic
drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the
information we have available.

Drug Coverage Information

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