Page 93 - Cover Letter and Evaluation for Amy Prack

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 Giant Eagle Pharmacy #6515
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Bystolic TAB 10MG Deductible $150.90 $150.90
1 Famotidine TAB 20MG Deductible $3.50 $3.50
Sertraline Hcl TAB 50MG Deductible $2.81 $2.81
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $157.21 $157.21
2 MONTH 2 TOTAL $152.41 $157.21
3 Est. annual costs if MONTH 3 TOTAL $53.31 $157.21
4 you get monthly MONTH 4 TOTAL $53.31 $157.21
5 refills at a Giant MONTH 5 TOTAL $53.31 $157.21
6 Eagle pharmacy = MONTH 6 TOTAL $53.31 $157.21
7 MONTH 7 TOTAL $53.31 $157.21
8 $842.72. MONTH 8 TOTAL $53.31 $157.21
9 MONTH 9 TOTAL $53.31 $157.21
10 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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