Page 47 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens #04197 CVS Pharmacy Mail Order Pharmacy

Walgreens #04197 - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Initial Coverage Coverage Catastrophic
OF DRUG Frequency Level[?] Gap[?] Coverage[?]
Bupropion Hcl TAB 300MG XL Every 1
$48.30 $8.00 $8.00 7 $3.35
Month
Finasteride (5Mg) TAB 5MG Every 1
$13.04 $2.00 $2.00 7 $3.35
Month
Losartan
Potassium/Hydrochlorothiazide $7.44 Every 1 $2.00 $2.00 7 $3.35
TAB 100-25 Month
Metoprolol Succinate Er TAB 25MG Every 1
ER $22.19 Month $2.00 $2.00 7 $3.35
Omeprazole CAP 40MG Every 1
$10.65 $8.00 $8.00 7 $3.35
Month
Proair HFA AER 16 Every 2
$61.90 $61.90 $21.66 $8.35
Months
Tamsulosin Hcl CAP 0.4MG Every 1
$9.91 $2.00 $2.00 7 $3.35
Month
Trazodone Hcl TAB 50MG Every 1
$4.43 $2.00 $2.00 7 $3.35
Month
Truvada TAB Every 1
$1,694.23 $559.10 $592.98 $84.71
Month
MONTHLY TOTALS: $1,872.09 $647.00 $640.64 $116.51

7 The price displayed for this drug may be lower than what you would typically pay during this period because of additional gap coverage offered by this plan.
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

Walgreens #04197 CVS Pharmacy Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$647 $585 $633 $619 $368 $108 $117 $108 $117 $108 $117 $108

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.

Drug Coverage Information

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H0609&plnid=028&sgmntid=0#plan_drug_cost 2/4