Page 88 - 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 Costco Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Finasteride (5Mg) TAB 5MG Deductible $5.80 $5.80
1 Pravastatin Sodium TAB 40MG Deductible $13.90 $13.90
Tamsulosin Hcl CAP 0.4MG Deductible $14.20 $14.20
Drug Premium NA $17.00 n/a
MONTH 1 TOTAL $50.90 $33.90
2 MONTH 2 TOTAL $50.90 $33.90
3 MONTH 3 TOTAL $50.90 $33.90
4 MONTH 4 TOTAL $50.90 $33.90
If you had been enrolled in
5 MONTH 5 TOTAL $50.90 $33.90
this plan for all 12 months
6 MONTH 6 TOTAL $50.90 $33.90
and had used monthly refills
7 MONTH 7 TOTAL $50.90 $33.90
from Costco, your total costs
8 MONTH 8 TOTAL $50.90 $33.90
would have been $610.80
9 MONTH 9 TOTAL $50.90 $33.90
(including premiums, co-
10 MONTH 10 TOTAL $50.90 $33.90
pays, and deductible)
11 MONTH 11 TOTAL $50.90 $33.90
12 MONTH 12 TOTAL $50.90 $33.90

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