Page 80 - Evaluation for 2018

12/23/2017 Your Plan Results
Asuris TruAdvantage + Rx Classic (PPO) (H5010-002-0)
Organization: Asuris Northwest Health
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $104.00 Annual Drug Doctor Choice: All Your Drugs on $5,000 Enroll
Deductible: Any Doctor Formulary :Yes
Pharmacy Drug: $63.70 $295 4 out of 5
Status: Health: Out of Pocket Drug Restrictions: stars
Standard Cost- $40.30 Health Plan Spending Yes
Sharing Deductible: $0 Limit: $10,000 Lower Your Drug
Part B Drug Copay/ In and Out-of- Costs
Annual: Premium Coinsurance: $0 network
Reduction - $40, 27% - $6,700 In- MTM Program :
Mail Order :No 40% network Yes
Annual: $1,079

Asuris TruAdvantage + Rx Enhanced (PPO) (H5010-004-0)
Organization: Asuris Northwest Health
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $247.00 Annual Drug Doctor Choice: All Your Drugs on $6,140 Enroll
Deductible: $0 Any Doctor Formulary :Yes
Pharmacy Drug: $99.20 4 out of 5
Status: Health: Health Plan Out of Pocket Drug Restrictions: stars
Standard Cost- $147.80 Deductible: $0 Spending Yes
Sharing Drug Copay/ Limit: $8,300 Lower Your Drug
Part B Coinsurance: $0 In and Out-of- Costs
Annual: Premium - $40, 33% - network
Reduction 40% $5,000 In- MTM Program :
Mail Order :No network Yes
Annual: $1,214

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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