Page 85 - Evaluation with Cover Letter for Henry Rose

9/16/2017 Your Medicare Health Plan Details
Costco Pharmacy - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Finasteride (5Mg) Every 1
$5.80 $5.80 $5.80 $2.96 $3.30
TAB 5MG Month
Pravastatin Sodium Every 1
$13.90 $13.90 $13.90 $7.09 $3.30
TAB 40MG Month
Tamsulosin Hcl CAP Every 1
$14.20 $14.20 $14.20 $7.24 $3.30
0.4MG Month
MONTHLY TOTALS: $33.90 $33.90 $33.90 $17.29 $9.90

Estimated Monthly Drug Costs

Costco Pharmacy Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A N/A N/A N/A N/A N/A N/A N/A N/A $51 $51 $51

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Graph depicts an estimate of your monthly prescription drug costs, including any applicable premium for this plan.
Actual costs may vary.
View a more detailed explanation of these costs.

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Finasteride (5Mg) TAB 5MG
Tier 2: Generic Yes
Pravastatin Sodium TAB 40MG
Tier 2: Generic Yes
Tamsulosin Hcl CAP 0.4MG
Tier 2: Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
8 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List

Add/Edit Drugs

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