Page 115 - Cover Letter & Evaluation for David Steenburgen

12/7/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy # Costco Pharmacy Mail Order Pharmacy

Mail Order Pharmacy
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Amlodipine Besylate Every 3
TAB 5MG $12.99 Months $8.00 $8.00 $5.72 $3.35
Quinapril Hcl TAB Every 3
40MG $18.10 Months $8.00 $8.00 $7.96 $3.35

MONTHLY TOTALS: $31.09 $16.00 $16.00 $13.68 $6.70

Estimated Monthly Drug Costs

CVS Pharmacy # Costco Pharmacy Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$36 $20 $20 $36 $20 $20 $36 $20 $20 $36 $20 $20

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 [?]
Amlodipine Besylate TAB 5MG
Tier 2: Generic
Quinapril Hcl TAB 40MG
Tier 2: Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

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

Add/Edit Drugs

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