Page 73 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details

Estimated Full Cost the Plan Charges Medicare for Your Drugs

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 Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Bupropion Hcl TAB 300MG XL Every 1
$47.64 $47.64 $47.00 $20.96 $3.35
Month
Finasteride (5Mg) TAB 5MG Every 1
$1.64 $1.64 $1.64 $1.64 $1.64
Month
Losartan
Potassium/Hydrochlorothiazide $1.64 Every 1 $1.64 $1.64 $1.64 $1.64
Month
TAB 100-25
Metoprolol Succinate Er TAB Every 1
25MG ER $7.65 Month $7.00 $7.00 $7.00 7 $3.35
Omeprazole CAP 40MG Every 1
$1.60 $1.60 $1.60 $1.60 $1.60
Month
Proair HFA AER Every 2
$68.44 $68.44 $68.44 $68.44 $68.44
Months
Tamsulosin Hcl CAP 0.4MG Every 1
$7.56 $7.00 $7.00 $7.00 7 $3.35
Month
Trazodone Hcl TAB 50MG Every 1
$7.18 $7.00 $7.00 $7.00 7 $3.35
Month
Truvada TAB Every 1
$1,656.40 $1,656.40 $513.48 $579.74 $82.82
Month
MONTHLY TOTALS: $1,799.75 $1,798.36 $654.80 $695.02 $169.54
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.

Estimated Monthly Drug Costs

Walgreens #04197 CVS Pharmacy Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$720 $632 $759 $673 $585 $147 $216 $147 $216 $147 $216 $147

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.

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0#plan_drug_cost 2/4