Page 91 - Cover Letter and Evaluation for Debbie Workman

12/13/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens #7846 CVS Pharmacy # Mail Order Pharmacy

Mail Order Pharmacy
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Atorvastatin Calcium Every 3
TAB 10MG $14.80 Months $0.00 $0.00 $6.51 $3.35
Clonazepam TAB 2MG Every 3
$17.44 $9.00 $9.00 $7.67 $3.35
Months
Levothyroxine Sodium Every 3
$40.55 $0.00 $0.00 $17.84 $3.35
TAB 75MCG Months
Pantoprazole Sodium Every 3
$33.18 $9.00 $9.00 $14.60 $3.35
TAB 40MG Months
MONTHLY TOTALS: $105.97 $18.00 $18.00 $46.62 $13.40

Estimated Monthly Drug Costs

Walgreens #7846 CVS Pharmacy # Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$31 $13 $13 $31 $13 $13 $31 $13 $13 $31 $13 $13

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Graph depicts an estimate of your monthly prescription drug costs, including any applicable premium for this plan.
Actual costs may vary.
View a more detailed explanation of these costs.

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Atorvastatin Calcium TAB 10MG
Tier 1: Preferred Generic
Clonazepam TAB 2MG
Tier 2: Generic Yes
Levothyroxine Sodium TAB 75MCG
Tier 1: Preferred Generic
Pantoprazole Sodium TAB 40MG
Tier 2: Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S7694&plnid=030&sgmntid=0 2/3