Page 84 - Cover Letter and Evaluation for Debbie Workman

12/13/2017 Monthly Cost Chart
Monthly Cost Chart

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Monthly Cost Chart
Walgreens #7846
CVS Pharmacy #
Mail Order Pharmacy
AARP MedicareComplete Plan 1 (HMO)
(H1286 - 002) Plan Type: HMO
Detailed Monthly costs for Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Atorvastatin Calcium TAB Deductible $0.00 $24.60
1 10MG
Clonazepam TAB 2MG Deductible $0.00 $19.17
Levothyroxine Sodium TAB 75MCG Deductible $0.00 $34.98
Pantoprazole Sodium TAB 40MG Deductible $0.00 $18.55
Drug Premium NA $17.00 n/a
MONTH 1 TOTAL $17.00 $97.30
2 MONTH 2 TOTAL $17.00 $0.00
3 MONTH 3 TOTAL $17.00 $0.00
4 MONTH 4 TOTAL $17.00 $97.30
5 MONTH 5 TOTAL $17.00 $0.00
6 MONTH 6 TOTAL $17.00 $0.00
7 MONTH 7 TOTAL $17.00 $97.30
8 MONTH 8 TOTAL $17.00 $0.00
9 MONTH 9 TOTAL $17.00 $0.00
10 MONTH 10 TOTAL $17.00 $97.30
11 MONTH 11 TOTAL $17.00 $0.00
12 MONTH 12 TOTAL $17.00 $0.00

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https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanFinderDRxIntegrationId=029c6eadd6fb47d5bf8216c28174b43c882037749628&… 1/1