Page 93 - Cover letter and evaluation for Michele Buros

Your Plan Results https://www.medicare.gov/find-a-plan/results/planresults/plan-list.aspx

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 $295.00 Annual Drug Doctor Choice: All Your Drugs on $6,460 Enroll
Deductible: $0 Any Doctor Formulary :Yes
Pharmacy Drug: 4 out of 5
Status: $106.10 Health Plan Out of Pocket Drug Restrictions: stars
Preferred Cost- Health: Deductible: $0 Spending Limit: No
Sharing $188.90 Drug Copay/ $10,000 In and Lower Your Drug
Coinsurance: Out-of-network Costs
Cost as of Today: Part B $0 - $90, 33% $6,700 In-
$1,061 Premium network MTM Program :
Reduction Yes
Mail Order :No
Cost as of Today:
$1,061
Security Blue HMO Deluxe (HMO) (H3957-020-0)
Organization: Highmark Choice Company
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 $270.50 Annual Drug Doctor Choice: All Your Drugs on $5,980 Enroll
Deductible: $0 Plan Doctors Formulary :Yes
Pharmacy Drug: for Most 4 out of 5
Status: $112.10 Health Plan Services Drug Restrictions: stars
Standard Cost- Health: Deductible: $0 No
Sharing $158.40 Drug Copay/ Out of Pocket Lower Your Drug
Coinsurance: Spending Limit: Costs
Cost as of Today: Part B $0 - $100, $6,700 In-
$1,121 Premium 33% network MTM Program :
Reduction Yes
Mail Order :No
Cost as of Today:
$1,121
Community Blue Medicare HMO Prestige (HMO) (H3957-039-0)
Organization: Highmark Choice Company
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 $197.00 Annual Drug Doctor Choice: All Your Drugs on $4,820 Enroll
Deductible: $0 Plan Doctors Formulary :Yes
Pharmacy Drug: for Most 4 out of 5
Status: $114.10 Health Plan Services Drug Restrictions: stars
Preferred Cost- Health: Deductible: $0 No
Sharing $82.90 Drug Copay/ Out of Pocket Lower Your Drug
Spending Limit:
Coinsurance: Costs
Cost as of Today: Part B $0 - $90, 33% $6,700 In-
$1,141 Premium network MTM Program :
Reduction Yes
Mail Order :No
Cost as of Today:
$1,141
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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