Page 177 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 15206
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 1859577088
and more coverage and star ratings.
Password Date: 02/05/2019
Important Coverage Information

Symbols

A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage

* Estimated

Advantra Gold (PPO) PO Box 7087 Overall Star Rating: Enroll
London, KY 40742 Members: 1- [?]
(H5522-001-0) 800-290-0190 711 (TTY/TDD)
Non Members: 1-855-275-6627 4 out of 5 stars
Organization: Coventry Health Care 711 (TTY/TDD)
Plan Type: Local Preferred
Provider Organization

Fixed Costs

Monthly Drug Plan Premium [?] $39.30
Monthly Health Plan Premium [?] $7.70

Annual Drug Deductible [?] $0.00

Medicare costs at a glance

Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs

Cost For Rest of Year (based on enrollment today) [?]
CVS Pharmacy #17618 $5,079.55
Walgreens #9281 $5,115.54
Mail Order Pharmacy $7,474.50

Lower your drug costs
Estimated Full Cost the Plan Charges Medicare for Your Drugs

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5522&plnid=001&sgmntid=0#plan_drug_cost 1/3