Page 78 - Cover Letter and Evaluation for Amy Prack

Monthly Cost Chart

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Monthly Cost Chart
Giant Eagle Pharmacy #6515
Mail Order Pharmacy
AARP MedicareComplete Plan 2 (HMO)
(H5253 - 053) 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 Deductible $125.00 $423.30
1 Famotidine TAB 20MG Deductible $0.00 $20.51
Sertraline Hcl TAB 50MG Deductible $0.00 $16.22
Drug Premium NA $22.20 n/a
MONTH 1 TOTAL $147.20 $460.03
2 MONTH 2 TOTAL $22.20 $0.00
3 MONTH 3 TOTAL $22.20 $0.00
4 If you switch to mail- MONTH 4 TOTAL $147.20 $460.03
5 order refills, your MONTH 5 TOTAL $22.20 $0.00
6 est. annual costs in MONTH 6 TOTAL $22.20 $0.00
7 this plan are MONTH 7 TOTAL $147.20 $460.03
8 $766.40. That MONTH 8 TOTAL $22.20 $0.00
9 MONTH 9 TOTAL $22.20 $0.00
10 amount includes MONTH 10 TOTAL $147.20 $460.03
11 premiums, MONTH 11 TOTAL $22.20 $0.00
12 deductible, and co- MONTH 12 TOTAL $22.20 $0.00
payments.

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