Page 60 - Cover Letter and Evaluation for Amy Prack

Monthly Cost Chart

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Monthly Cost Chart
Giant Eagle Pharmacy #6515
Mail Order Pharmacy
Humana Gold Plus H6622-013 (HMO)
(H6622 - 013) Plan Type: HMO
Detailed Monthly costs for Mail Order Pharmacy
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Bystolic TAB 10MG Initial Coverage Level $131.00 $451.71
1 Famotidine TAB 20MG Initial Coverage Level $0.00 $9.99
Sertraline Hcl TAB 50MG Initial Coverage Level $0.00 $9.99
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $131.00 $471.69
2 MONTH 2 TOTAL $0.00 $0.00
3 MONTH 3 TOTAL $0.00 $0.00
4 Estimated annual MONTH 4 TOTAL $131.00 $471.69
5 costs for mail-order MONTH 5 TOTAL $0.00 $0.00
6 refills are $524. MONTH 6 TOTAL $0.00 $0.00
7 MONTH 7 TOTAL $131.00 $471.69
8 MONTH 8 TOTAL $0.00 $0.00
9 MONTH 9 TOTAL $0.00 $0.00
10 MONTH 10 TOTAL $131.00 $471.69
11 MONTH 11 TOTAL $0.00 $0.00
12 MONTH 12 TOTAL $0.00 $0.00

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