Page 181 - 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 Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Amitriptyline Hcl TAB 25MG Initial Coverage Level $43.42 $43.42
1 Buspirone Hcl TAB 10MG Initial Coverage Level $0.00 $1.89
Humira PEN INJ 40MG/0.8 Initial Coverage Level \ Coverage Gap \ Catastrophic $4,647.29 $15,832.72
Coverage
Drug Premium NA $39.30 n/a
MONTH 1 TOTAL $4,730.01 $15,878.03
2 MONTH 2 TOTAL $39.30 $0.00
3 MONTH 3 TOTAL $39.30 $0.00
4 Annual costs if you MONTH 4 TOTAL $836.23 $15,878.03
5 get mail-order refills MONTH 5 TOTAL $39.30 $0.00
6 are $7,553.10. Costs MONTH 6 TOTAL $39.30 $0.00
7 include premiums, MONTH 7 TOTAL $836.23 $15,878.03
8 deductible, and co- MONTH 8 TOTAL $39.30 $0.00
9 payments. MONTH 9 TOTAL $39.30 $0.00
10 MONTH 10 TOTAL $836.23 $15,878.03
11 MONTH 11 TOTAL $39.30 $0.00
12 MONTH 12 TOTAL $39.30 $0.00

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