Page 92 - Cover Letter and Evaluation for Amy Prack
P. 92
Monthly Cost Chart
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Monthly Cost Chart
Giant Eagle Pharmacy #6515
Mail Order Pharmacy
HumanaChoice H5525-042 (PPO)
(H5525 - 042) Plan Type: Local Preferred Provider Organization
Detailed Monthly costs for Mail Order Pharmacy
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MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Bystolic TAB 10MG Deductible \ Initial Coverage Level $381.00 $451.71
1 Famotidine TAB 20MG Deductible $0.00 $12.99
Sertraline Hcl TAB 50MG Deductible $0.00 $12.99
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $381.00 $477.69
2 MONTH 2 TOTAL $0.00 $0.00
3 MONTH 3 TOTAL $0.00 $0.00
4 Est. annual costs for MONTH 4 TOTAL $131.00 $477.69
5 mail-order refills = MONTH 5 TOTAL $0.00 $0.00
6 MONTH 6 TOTAL $0.00 $0.00
7 $774. MONTH 7 TOTAL $131.00 $477.69
8 MONTH 8 TOTAL $0.00 $0.00
9 MONTH 9 TOTAL $0.00 $0.00
10 MONTH 10 TOTAL $131.00 $477.69
11 MONTH 11 TOTAL $0.00 $0.00
12 MONTH 12 TOTAL $0.00 $0.00
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