Page 178 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy #17618 Walgreens #9281 Mail Order Pharmacy

CVS Pharmacy #17618 - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Initial Coverage Coverage Catastrophic
DRUG Frequency Level[?] Gap[?] Coverage[?]
Amitriptyline Hcl TAB Every 1
25MG $14.88 Month $14.88 $5.51 $3.40
Buspirone Hcl TAB Every 1
10MG $1.03 Month $0.00 $0.00 7 $1.03
Humira PEN INJ Every 1
$5,464.24 $1,803.20 $1,366.06 $273.21
40MG/0.8 Month
MONTHLY TOTALS: $5,480.15 $1,818.08 $1,371.57 $277.64
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

CVS Pharmacy #17618 Walgreens #9281 Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A N/A $1,725 $819 $317 $317 $317 $317 $317 $317 $317 $317

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.

Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription
drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its
coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic
drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the
information we have available.

Drug Coverage Information

Restrictions Your doctor's prior
SELECTED DRUGS TIER PRIOR QUANTITY STEP
authorization may be
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Amitriptyline Hcl TAB 25MG needed before you
Tier 3: Preferred Brand Yes
Buspirone Hcl TAB 10MG can get these two Rx
Tier 2: Generic drugs.
Humira PEN INJ 40MG/0.8
Tier 5: Specialty Tier Yes Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5522&plnid=001&sgmntid=0#plan_drug_cost 2/3