Page 56 - 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 Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Clindamycin 1%/Benzoyl Deductible $279.79 $279.79
1 Peroxide 5% GEL 1-5%
Diazepam TAB 2MG Deductible $3.28 $3.28
Digoxin TAB 0.25MG Deductible $8.00 $58.40
Fluoxetine Hcl CAP 20MG Deductible $2.00 $16.52
Fluticasone Propionate Nasal SPR 50MCG Deductible $8.00 $15.13
Metronidazole Topical GEL 1% Deductible $8.00 $136.47
Tramadol Hcl TAB 50MG Deductible $8.00 $24.83
Warfarin Sodium TAB 6MG Deductible $2.00 $26.05
Drug Premium NA $24.00 n/a
MONTH 1 TOTAL $343.07 $560.47
2 MONTH 2 TOTAL $24.00 $0.00
3 MONTH 3 TOTAL $24.00 $0.00
Annual costs for
4 MONTH 4 TOTAL $343.07 $560.47
5 mail-order refills is MONTH 5 TOTAL $24.00 $0.00
6 approximately MONTH 6 TOTAL $24.00 $0.00
7 $1,564. Your costs MONTH 7 TOTAL $343.07 $560.47
8 for the last one-half MONTH 8 TOTAL $24.00 $0.00
9 of 2019 are approx. MONTH 9 TOTAL $24.00 $0.00
10 one-half that MONTH 10 TOTAL $343.07 $560.47
11 amount -- that MONTH 11 TOTAL $24.00 $0.00
12 MONTH 12 TOTAL $24.00 $0.00
includes premiums,
co-pays, and
deductible. w32

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