Page 81 - Cover letter and evaluation for Michele Buros

Monthly Cost Chart https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanF...

Monthly Cost Chart

Show monthly cost chart for:
M ont hly Cos t Char t
Giant Eagle Pharmacy 0060 $333.84 at CVS
CVS Pharmacy
Mail Order Pharmacy
Aetna Medicare Gold Plan (PPO)
(H5521 - 122) Plan Type: Local Preferred Provider Organization
Detailed Monthly costs for CVS Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Atorvastatin Calcium TAB Initial Coverage Level $1.03 $1.03
1 10MG
Hydrochlorothiazide TAB 25MG Initial Coverage Level $1.69 $1.69
Drug Premium NA $25.10 n/a
MONTH 1 TOTAL $27.82 $2.72
2 MONTH 2 TOTAL $27.82 $2.72
3 MONTH 3 TOTAL $27.82 $2.72
4 MONTH 4 TOTAL $27.82 $2.72
5 MONTH 5 TOTAL $27.82 $2.72
6 MONTH 6 TOTAL $27.82 $2.72
7 MONTH 7 TOTAL $27.82 $2.72
8 MONTH 8 TOTAL $27.82 $2.72
9 MONTH 9 TOTAL $27.82 $2.72
10 MONTH 10 TOTAL $27.82 $2.72
11 MONTH 11 TOTAL $27.82 $2.72
12 MONTH 12 TOTAL $27.82 $2.72

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