Page 82 - Cover letter and evaluation for Michele Buros
P. 82
Monthly Cost Chart https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanF...
Monthly Cost Chart
Show monthly cost chart for: $301.20 mail order
M ont hly Cos t Char t
Giant Eagle Pharmacy 0060
CVS Pharmacy
Mail Order Pharmacy
Aetna Medicare Gold Plan (PPO)
(H5521 - 122) Plan Type: Local Preferred Provider Organization
Detailed Monthly costs for Mail Order Pharmacy
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Atorvastatin Calcium TAB Initial Coverage Level $0.00 $1.88
1 10MG
Hydrochlorothiazide TAB 25MG Initial Coverage Level $0.00 $3.87
Drug Premium NA $25.10 n/a
MONTH 1 TOTAL $25.10 $5.75
2 MONTH 2 TOTAL $25.10 $0.00
3 MONTH 3 TOTAL $25.10 $0.00
4 MONTH 4 TOTAL $25.10 $5.75
5 MONTH 5 TOTAL $25.10 $0.00
6 MONTH 6 TOTAL $25.10 $0.00
7 MONTH 7 TOTAL $25.10 $5.75
8 MONTH 8 TOTAL $25.10 $0.00
9 MONTH 9 TOTAL $25.10 $0.00
10 MONTH 10 TOTAL $25.10 $5.75
11 MONTH 11 TOTAL $25.10 $0.00
12 MONTH 12 TOTAL $25.10 $0.00
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