Page 112 - Cover Letter & Evaluation for David Steenburgen

12/7/2017 Your Plan Results
Cigna-HealthSpring Rx Secure (PDP) (S5617-138-0)
Organization: Cigna-HealthSpring Rx
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $31.40 Annual Drug Deductible: All Your Drugs on Enroll
$405 Formulary :Yes
Pharmacy Status: 2 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $2 - $34, 25% - 40% Lower Your Drug Costs
Annual: MTM Program : Yes
Mail Order
Annual: $435
SilverScript Choice (PDP) (S5601-056-0)
Organization: SilverScript
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $28.50 Annual Drug Deductible: All Your Drugs on Enroll
$100 Formulary :Yes
Pharmacy Status: 4 out of 5 stars
Preferred Cost- Drug Copay/ Coinsurance: Drug Restrictions: No
Sharing $3 - $41, 31% - 45% Lower Your Drug Costs
Annual: MTM Program : Yes

Mail Order
Annual: $439
Magellan Rx Medicare Basic (PDP) (S4607-023-0)
Organization: Magellan Rx Medicare
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $31.70 Annual Drug Deductible: All Your Drugs on Enroll
$405 Formulary :Yes
Pharmacy Status: 2 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: No
Sharing $1 - $3, 14% - 50% Lower Your Drug Costs
Annual: MTM Program : Yes
Mail Order
Annual: $466
EnvisionRxPlus (PDP) (S7694-028-0)
Organization: EnvisionRx Plus
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $33.10 Annual Drug Deductible: All Your Drugs on Enroll
$405 Formulary :Yes
Pharmacy Status: 3 out of 5 stars
Preferred Cost- Drug Copay/ Coinsurance: Drug Restrictions: No
Sharing $1 - $3, 15% - 28% Lower Your Drug Costs
Annual: MTM Program : Yes
Mail Order
Annual: $489

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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