Page 84 - Evaluation with Cover Letter for Henry Rose

9/16/2017 Your Medicare Health Plan Details

These are the cost and coverage
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details for the Humana-Walmart
Your Plan Details Rx Plan.

Zip Code: 22202
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 9912552448
and more coverage and star ratings.
Password Date: 09/16/2017
Important Coverage Information

Symbols

Nationwide Coverage
* Estimated

Humana Walmart Rx Plan 500 West Main Street Overall Star Rating: [?] Enroll
Louisville, KY 40202
(PDP)
(S5884-153-0) Members: 3 out of 5 stars
1-800-281-6918 Call this number to
Organization: Humana Insurance 711 (TTY/TDD)
Company enroll.
Non Members:
Plan Type: 1-800-706-0872
711 (TTY/TDD)

NOTE: Health Plan Benefits are based on Original Medicare

Fixed Costs

Monthly Drug Plan Premium [?] $17.00

Monthly Health Plan Premium [?] N/A

Annual Drug Deductible [?] $400.00
Medicare costs at a glance

Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs

Cost For Rest of Year (based on enrollment today) [?]
Costco Pharmacy $152.70
Mail Order Pharmacy $75.00
Lower your drug costs

Estimated Full Cost the Plan Charges Medicare for Your Drugs

Drug Costs During Coverage Levels

Costco Pharmacy Mail Order Pharmacy

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5884&plnid=153&sgmntid=0 1/3