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2/24/2017 Your Plan Results
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug Costs:
[?] Programs: [?]
Retail $110.00 Annual Drug Doctor Choice: All Your Drugs on $6,280 Enroll
Deductible: Plan Doctors for Formulary: Yes
Pharmacy Status: Drug: $44.70 $200 Most Services 3.5 out of 5
Preferred Cost­ Health: Drug Restrictions: stars
Sharing $65.30 Health Plan Out of Pocket Yes
Deductible: $0
Spending
Cost as of Today: Part B Drug Copay/ Limit: $6,700 Lower Your Drug
Costs
$1,767 Premium Coinsurance: $7 In and Out­of­
Reduction ­ $97, 29% network MTM Program [?]
Mail Order [?] : No : Yes
Cost as of Today:
$1,909
Health First Rewards Plan (HMO) (H1099­014­0)
Organization: Health First Health Plans, Inc.
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug Costs:
[?] Programs: [?]
Retail $0.00 Annual Drug Doctor Choice: All Your Drugs on $6,680 Enroll
Deductible: $0 Plan Doctors for Formulary: No
Pharmacy Status: Drug: $0.00 Most Services 4 out of 5
Standard Cost­ Health: $0.00 Health Plan Drug Restrictions: stars
Sharing Deductible: $0 Out of Pocket Yes
Part B Drug Copay/ Spending Lower Your Drug
Cost as of Today: Premium Coinsurance: $0 Limit: $6,650 Costs
$2,666 Reduction ­ $90, 33% In­network
[?] : No MTM Program [?]
Mail Order : Yes
Cost as of Today:
$3,103

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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