Page 79 - Cover letter and evaluation for Thomas Barr

10/16/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Broadneck Pharmacy CVS Pharmacy # Mail Order Pharmacy

Broadneck Pharmacy - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Deductible[?] Initial Coverage Coverage Catastrophic
DRUG Frequency Level[?] Gap[?] Coverage[?]
Simvastatin TAB Every 1
20MG $3.76 Month $3.76 $3.76 $1.65 $3.35
MONTHLY $3.76 $3.76 $3.76 $1.65 $3.35
TOTALS:

Estimated Monthly Drug Costs

Broadneck Pharmacy CVS Pharmacy # Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$16 $16 $16 $16 $16 $16 $16 $16 $16 $16 $16 $16

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 [?]
Simvastatin TAB 20MG
Tier 1: Preferred Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

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

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S7694&plnid=005&sgmntid=0 2/3