Page 55 - Cover Letter and Appendices for Melanie April 2019

Monthly Cost Chart https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanF...

Monthly Cost Chart

Show monthly cost chart for:
M ont hly Cos t Char t
CVS Pharmacy #05380
Walgreens #9908
Mail Order Pharmacy
Express Scripts Medicare - Saver (PDP)
(S5660 - 238) Plan Type: PDP
Detailed Monthly costs for CVS Pharmacy #05380
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Clindamycin 1%/Benzoyl Deductible $173.28 $173.28
1 Peroxide 5% GEL 1-5%
Diazepam TAB 2MG Deductible $8.69 $8.69
Digoxin TAB 0.25MG Deductible $4.00 $16.66
Fluoxetine Hcl CAP 20MG Deductible $1.00 $7.70
Fluticasone Propionate Nasal SPR 50MCG Deductible $4.00 $7.24
Metronidazole Topical GEL 1% Deductible $12.00 $126.62
Tramadol Hcl TAB 50MG Deductible $12.00 $30.51
Warfarin Sodium TAB 6MG Deductible $1.00 $10.88
Drug Premium NA $24.00 n/a
If you had been enrolled in MONTH 1 TOTAL $239.97 $381.58
2 this plan for the entire 2019 MONTH 2 TOTAL $34.00 $42.48
3 MONTH 3 TOTAL $207.28 $215.76
4 plan year, your total drug MONTH 4 TOTAL $66.69 $208.30
5 costs -- including premiums, MONTH 5 TOTAL $207.28 $215.76
6 deductible, and co-pays -- MONTH 6 TOTAL $34.00 $42.48
7 would be $1,578.44 if you get MONTH 7 TOTAL $239.97 $381.58
monthly refills at a CVS
8 MONTH 8 TOTAL $34.00 $42.48
9 Pharmacy. Your costs for the MONTH 9 TOTAL $207.28 $215.76
last six months of this year
10 MONTH 10 TOTAL $66.69 $208.30
11 will be approx. one-half that MONTH 11 TOTAL $207.28 $215.76
12 amount. MONTH 12 TOTAL $34.00 $42.48

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