Page 59 - Cover Letter and Evaluation for Amy Prack
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Giant Eagle Pharmacy #6515
Mail Order Pharmacy
Humana Gold Plus H6622-013 (HMO)
(H6622 - 013) Plan Type: HMO
Detailed Monthly costs for Giant Eagle Pharmacy #6515
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MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Bystolic TAB 10MG Initial Coverage Level $47.00 $150.90
1 Famotidine TAB 20MG Initial Coverage Level $3.50 $3.50
Sertraline Hcl TAB 50MG Initial Coverage Level $2.81 $2.81
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $53.31 $157.21
2 MONTH 2 TOTAL $53.31 $157.21
3 MONTH 3 TOTAL $53.31 $157.21
4 MONTH 4 TOTAL $53.31 $157.21
5 Estimated annual MONTH 5 TOTAL $53.31 $157.21
6 costs are $639.72. MONTH 6 TOTAL $53.31 $157.21
7 That amount MONTH 7 TOTAL $53.31 $157.21
includes premiums,
8 MONTH 8 TOTAL $53.31 $157.21
9 deductible, and co- MONTH 9 TOTAL $53.31 $157.21
10 payments MONTH 10 TOTAL $53.31 $157.21
11 MONTH 11 TOTAL $53.31 $157.21
12 MONTH 12 TOTAL $53.31 $157.21
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