Page 180 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Monthly Cost Chart
Monthly Cost Chart

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Monthly Cost Chart
CVS Pharmacy #17618
Walgreens #9281
Mail Order Pharmacy
Advantra Gold (PPO)
(H5522 - 001) Plan Type: Local Preferred Provider Organization
Detailed Monthly costs for CVS Pharmacy #17618
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Amitriptyline Hcl TAB 25MG Initial Coverage Level $14.88 $14.88
1 Buspirone Hcl TAB 10MG Initial Coverage Level $0.00 $1.03
Humira PEN INJ 40MG/0.8 Initial Coverage Level \ Coverage Gap $1,670.39 $5,464.24
Drug Premium NA $39.30 n/a
MONTH 1 TOTAL $1,724.57 $5,480.15
2 MONTH 2 TOTAL $819.46 $5,480.15
3 MONTH 3 TOTAL $316.94 $5,480.15
12-month costs if
4 MONTH 4 TOTAL $316.94 $5,480.15
5 you get refills at a MONTH 5 TOTAL $316.94 $5,480.15
6 CVS Pharmacy are MONTH 6 TOTAL $316.94 $5,480.15
7 $5,713.43. That MONTH 7 TOTAL $316.94 $5,480.15
8 amount includes MONTH 8 TOTAL $316.94 $5,480.15
9 premiums, MONTH 9 TOTAL $316.94 $5,480.15
10 deductibles, and co- MONTH 10 TOTAL $316.94 $5,480.15
11 payments. MONTH 11 TOTAL $316.94 $5,480.15
12 MONTH 12 TOTAL $316.94 $5,480.15

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