Page 194 - 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 Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Amitriptyline Hcl TAB 25MG Initial Coverage Level $17.81 $17.81
1 Buspirone Hcl TAB 10MG Initial Coverage Level $10.94 $10.94
Humira PEN INJ 40MG/0.8 Initial Coverage Level \ Coverage Gap \ Catastrophic $4,617.16 $14,901.38
Coverage
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $4,645.91 $14,930.13
2 MONTH 2 TOTAL $0.00 $0.00
3 In this plan your MONTH 3 TOTAL $0.00 $0.00
4 MONTH 4 TOTAL $751.87 $14,930.13
estimated annual
5 MONTH 5 TOTAL $0.00 $0.00
costs if you get mail-
6 MONTH 6 TOTAL $0.00 $0.00
order refills is
7 $6,901.52. That MONTH 7 TOTAL $751.87 $14,930.13
8 MONTH 8 TOTAL $0.00 $0.00
9 amount includes MONTH 9 TOTAL $0.00 $0.00
10 premiums, MONTH 10 TOTAL $751.87 $14,930.13
deductible, and co-
11 MONTH 11 TOTAL $0.00 $0.00
payments.
12 MONTH 12 TOTAL $0.00 $0.00

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