Page 119 - Cover Letter & Evaluation for David Steenburgen

12/7/2017 Your Medicare Health Plan Details
Costco Pharmacy CVS Pharmacy #
Costco Pharmacy - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Amlodipine Besylate Every 1
$1.09 $0.00 $0.00 $0.00 7 $1.09
TAB 5MG Month
Quinapril Hcl TAB Every 1
$1.85 $0.00 $0.00 $0.00 7 $1.85
40MG Month
MONTHLY TOTALS: $2.94 $0.00 $0.00 $0.00 $2.94

7 The price displayed for this drug may be lower than what you would typically pay during this period because of additional gap coverage offered by this plan.

Estimated Monthly Drug Costs

Costco Pharmacy CVS Pharmacy #

Monthly Costs (based on January enrollment)
$13 $13 $13 $13 $13 $13 $13 $13 $13 $13 $13 $13

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 1: Preferred Generic
Quinapril Hcl TAB 40MG
Tier 1: Preferred Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is not available.
Pharmacy Network [?]
2 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5810&plnid=294&sgmntid=0 2/3