Page 23 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Plan Results
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $0.00 Annual Drug Doctor Choice: All Your Drugs on $6,870 Enroll
Deductible: Any Doctor Formulary :No
Pharmacy Drug: $0.00 $365 4 out of 5
Status: Health: Out of Pocket Drug Restrictions: stars
Preferred Cost- $0.00 Health Plan Spending Yes
Sharing Deductible: Limit: $10,000 Lower Your Drug
Part B $1,500 annual In and Out-of- Costs
Annual: $3,992 Premium deductible network
Reduction Drug Copay/ $6,700 In- MTM Program :
Mail Order :Yes Coinsurance: $5 network Yes
Annual: $6,659 - $100, 25%

HumanaChoice H5216-037 (PPO) (H5216-037-0)
Organization: Humana Insurance Company
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $35.00 Annual Drug Doctor Choice: All Your Drugs on $7,580 Enroll
Deductible: Any Doctor Formulary :No
Pharmacy Drug: $0.00 $225 4 out of 5
Status: Health: Out of Pocket Drug Restrictions: stars
Preferred Cost- $35.00 Health Plan Spending Yes
Sharing Deductible: Limit: $10,000 Lower Your Drug
Part B $1,500 annual In and Out-of- Costs
Annual: $3,918 Premium deductible network
Reduction Drug Copay/ $5,900 In- MTM Program :
Mail Order :No Coinsurance: $2 network Yes
Annual: $6,708 - $100, 28%

HumanaChoice H5216-036 (PPO) (H5216-036-0)
Organization: Humana Insurance Company
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $140.00 Annual Drug Doctor Choice: All Your Drugs on $8,670 Enroll
Deductible: Any Doctor Formulary :No
Pharmacy Drug: $56.20 $225 4 out of 5
Status: Health: Out of Pocket Drug Restrictions: stars
Preferred Cost- $83.80 Health Plan Spending Yes
Sharing Deductible: Limit: $7,500 Lower Your Drug
Part B $1,000 annual In and Out-of- Costs
Annual: $4,620 Premium deductible network
Reduction Drug Copay/ $6,700 In- MTM Program :
Mail Order :No Coinsurance: $4 network Yes
Annual: $7,383 - $100, 28%

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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