Page 65 - Cover Letter and Evaluation for Bob Workman

10/25/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens #7846 CVS Pharmacy # Mail Order Pharmacy

Walgreens #7846 - 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[?]
Losartan Potassium TAB Every 1
50MG $6.07 Month $6.07 $6.07 $2.67 $3.35
Metoprolol Succinate Er Every 1
TAB 100MG ER $21.78 Month $20.00 $20.00 $9.58 $3.35
Montelukast Sodium TAB Every 1
$7.40 $7.40 $7.40 $3.26 $3.35
10MG Month
Ventolin HFA AER 16 Every 2
$25.80 $25.80 $25.80 $9.03 $8.35
Months
MONTHLY TOTALS: $61.05 $59.27 $59.27 $24.54 $18.40

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 #7846 CVS Pharmacy # Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$72 $46 $72 $46 $72 $46 $72 $46 $72 $46 $72 $46

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

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) AUTHORIZATION LIMITS THERAPY
[?] [?] [?] [?]
Losartan Potassium TAB 50MG
Tier 1: Preferred Generic
Metoprolol Succinate Er TAB 100MG
ER Tier 2: Generic
Montelukast Sodium TAB 10MG
Tier 1: Preferred Generic
Ventolin HFA AER
Tier 3: Preferred Brand Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

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