Page 193 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Monthly Cost Chart
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CVS Pharmacy #17618
Walgreens #9281
Mail Order Pharmacy
UPMC for Life HMO Premier Rx (HMO)
(H3907 - 046) Plan Type: HMO
Detailed Monthly costs for Walgreens #9281
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Amitriptyline Hcl TAB 25MG Initial Coverage Level $4.50 $4.50
1 Buspirone Hcl TAB 10MG Initial Coverage Level $2.50 $2.50
Humira PEN INJ 40MG/0.8 Initial Coverage Level \ Coverage Gap $1,588.05 $5,132.06
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $1,595.05 $5,139.06
2 MONTH 2 TOTAL $1,285.60 $5,139.06
3 MONTH 3 TOTAL $307.68 $5,139.06
Est. annual costs if
4 MONTH 4 TOTAL $262.50 $5,139.06
you get monthly
5 MONTH 5 TOTAL $262.50 $5,139.06
6 refills at a Walgreens MONTH 6 TOTAL $262.50 $5,139.06
7 Pharmacy is MONTH 7 TOTAL $262.50 $5,139.06
$5,550.84. That cost
8 MONTH 8 TOTAL $262.50 $5,139.06
includes premiums,
9 MONTH 9 TOTAL $262.50 $5,139.06
deductible, and co-
10 MONTH 10 TOTAL $262.50 $5,139.06
11 payments. MONTH 11 TOTAL $262.50 $5,139.06
12 MONTH 12 TOTAL $262.50 $5,139.06

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