Page 69 - APPENDICES for Bruno D. Manno
P. 69
f~=CC@ KD] W W ^ _`abc5de 8f`gh`ijwljmn oV[\ Z_ p V \ [ o qt 8iu
6 7 89 : ;QRSTQR f`gh` 3a4cmlumikmlum f h3cgvdfiuuwlmmx W^V yzW Wo _ {Z ^ W \ WV \ [ | y ^[ o Z WV \ [ | y ^[ o Z
!"#$%& '( ") *+ ,-.& /01%23 4
5 ?@ AB@CDE F>?=GH I J=?D KLM ANOPNq W 8ik W^V} \ yzW Wo _ {Z ^ W \
efr8de 8hs
<=>UVW X Y WZ[ \] W W ^ _`abc5de 8f`gh`ijkl mn oV[\ Z_ p V \ [ o t [ \ \[o ^YV 9 89 : ;@?D> I J=?D KLM ANOPQTQR W f`gh` 3a4cwl
ux W^V yzW Wo _ {Z ^ W \ WV \ [ | y ^[ o Z
efr8de 8hs
This is a list of the stand-alone
drug plans that have the lowest
costs for your Rx drugs in 2021.
Costs shown include premiums
and co-payments.
This plan's benefit
summary is in
Appendix D2
This plan's benefit
summary is in
Appendix D3