Page 57 - Cover Letter and Evaluation for Amy Prack

Giant Eagle Pharmacy #6515 Mail Order Pharmacy
Giant Eagle Pharmacy #6515 - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Initial Coverage Coverage Gap Catastrophic
DRUG Frequency Level[?] [?] Coverage[?]
Bystolic TAB 10MG $150.90 Every 1 Month $47.00 $37.72 $8.50
Famotidine TAB
$3.50 Every 1 Month $3.50 $1.30 $3.40
20MG
Sertraline Hcl TAB
$2.81 Every 1 Month $2.81 $1.04 $2.81
50MG
MONTHLY TOTALS: $157.21 $53.31 $40.06 $14.71

Estimated Monthly Drug Costs

Giant Eagle Pharmacy #6515 Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A N/A N/A N/A N/A $53 $53 $53 $53 $53 $53 $53

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.

Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription
drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its
coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic
drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the
information we have available.
Drug Coverage Information
Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Bystolic TAB 10MG
Tier 3: Preferred Brand Yes
Famotidine TAB 20MG
Tier 2: Generic
Sertraline Hcl TAB 50MG
Tier 1: Preferred Generic Yes
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 [?]

Drug List