Page 87 - Evaluation with Cover Letter for Henry Rose

9/16/2017 Monthly Cost Chart
Monthly Cost Chart

Show monthly cost chart for:
Monthly Cost Chart
Costco Pharmacy
Mail Order Pharmacy

Humana Walmart Rx Plan (PDP)
(S5884 - 153) Plan Type: PDP

Detailed Monthly costs for Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Finasteride (5Mg) TAB 5MG Deductible $8.00 $15.40
1 Pravastatin Sodium TAB 40MG Deductible $8.00 $39.70
Tamsulosin Hcl CAP 0.4MG Deductible $8.00 $40.60
Drug Premium NA $17.00 n/a
MONTH 1 TOTAL $41.00 $95.70
2 MONTH 2 TOTAL $17.00 $0.00
3 MONTH 3 TOTAL $17.00 $0.00
4 MONTH 4 TOTAL $41.00 $95.70
Total cost in 2017
5 MONTH 5 TOTAL $17.00 $0.00
is $300 using mail-
6 MONTH 6 TOTAL $17.00 $0.00
order refills. Costs
7 MONTH 7 TOTAL $41.00 $95.70
include co-pays,
8 MONTH 8 TOTAL $17.00 $0.00
deductible, and
9 MONTH 9 TOTAL $17.00 $0.00
premiums.
10 MONTH 10 TOTAL $41.00 $95.70
11 MONTH 11 TOTAL $17.00 $0.00
12 MONTH 12 TOTAL $17.00 $0.00

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https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanFinderDRxIntegrationId=6a9af265fde647b3aac9cec9a76bce35874440629861&… 1/1