Page 46 - Cover Letter and Evaluation for Amy Prack

Retail $204.00 Annual Drug Doctor All Your Drugs on $6,410 Enroll
Deductible: $0 Choice: Formulary: Yes 4 out of 5
Pharmacy Drug: $53.30 Any Doctor stars
Status: Health: Health Plan Drug Restrictions:
Preferred $150.70 Deductible: $250 Out of Yes
Cost-Sharing annual deductible Pocket Lower Your Drug
Part B Drug Copay/ Spending Costs
Cost as of Premium Coinsurance: $0 - Limit:
Today: $1,073 Reduction: $100, 33% $7,500 In MTM Program : Yes
No and Out-of-
Mail Order network
Cost as of $3,500 In-
Today: $1,273 network

MediGold Flexible Choice (PPO) (H1846-004-0)
Organization: MediGold
Estimated Monthly Deductibles [?] Health Drug Coverage [?] Estimated Overall
Annual Drug Premium: and Drug Copay Benefits: , Drug Restrictions Annual Health Star
Costs: [?] [?] [?] / Coinsurance: [?] [?] and Other and Drug Rating:
[?] Programs: Costs: [?] [?]
Retail $57.00 Annual Drug Doctor All Your Drugs on $5,330 3.5 out of Enroll
Deductible: $150 Choice: Formulary: Yes
Pharmacy Drug: $47.60 Any Doctor 5 stars
Status: Health: $9.40 Health Plan Drug Restrictions:
Standard Deductible: $0 Out of Yes
Cost-Sharing Part B Drug Copay/ Pocket Lower Your Drug
Premium Coinsurance: $2 - Spending Costs
Cost as of Reduction: $100, 30% Limit:
Today: $1,109 No $10,000 In MTM Program : Yes
and Out-of-
Mail Order network
Cost as of $5,000 In-
Today: $1,104 network

Anthem MediBlue Access (PPO) (H4036-010-1)
Organization: Anthem Blue Cross and Blue Shield
Estimated Monthly Deductibles [?] Health Drug Coverage [?] Estimated Overall
Annual Drug Premium: and Drug Copay Benefits: , Drug Restrictions Annual Health Star
Costs: [?] [?] [?] / Coinsurance: [?] [?] and Other and Drug Rating:
[?] Programs: Costs: [?] [?]
Retail $56.00 Annual Drug Doctor All Your Drugs on $5,200 Enroll
Deductible: $50 Choice: Formulary: Yes 4 out of 5
Pharmacy Drug: $56.00 Any Doctor stars
Status: Health: $0.00 Health Plan Drug Restrictions:
Preferred Deductible: $1,000 Out of Yes
Cost-Sharing Part B annual deductible Pocket Lower Your Drug
Premium Drug Copay/ Spending Costs
Cost as of Reduction: Coinsurance: $0 - Limit:
Today: $1,152 No $95, 32% $10,000 In MTM Program : Yes
and Out-of-
Mail Order network
Cost as of $6,400 In-
Today: $1,012 network

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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