Page 77 - Cover Letter and Evaluation for Amy Prack

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Giant Eagle Pharmacy #6515
Mail Order Pharmacy
AARP MedicareComplete Plan 2 (HMO)
(H5253 - 053) Plan Type: HMO
Detailed Monthly costs for Giant Eagle Pharmacy #6515
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Bystolic TAB 10MG Deductible $45.00 $151.27
1 Famotidine TAB 20MG Deductible $7.00 $7.00
Sertraline Hcl TAB 50MG Deductible $2.00 $3.71
Drug Premium NA $22.20 n/a
Est. annual costs for MONTH 1 TOTAL $76.20 $161.98
2 your drugs if you get MONTH 2 TOTAL $76.20 $161.98
3 MONTH 3 TOTAL $76.20 $161.98
4 monthly refills at a MONTH 4 TOTAL $76.20 $161.98
5 Giant Eagle MONTH 5 TOTAL $76.20 $161.98
6 pharmacy = $914.40. MONTH 6 TOTAL $76.20 $161.98
7 That amount MONTH 7 TOTAL $76.20 $161.98
includes premiums,
8 MONTH 8 TOTAL $76.20 $161.98
9 deductible, and co- MONTH 9 TOTAL $76.20 $161.98
10 payments. MONTH 10 TOTAL $76.20 $161.98
11 MONTH 11 TOTAL $76.20 $161.98
12 MONTH 12 TOTAL $76.20 $161.98

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