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3/7/2017 MonthlyCostChart
Show monthly cost chart for:
M o n th ly C o s t C h a rt
CVS Pharmacy #
Walgreens #1990
Mail Order Pharmacy
First Health Part D Value Plus (PDP)
(S5768 134) Plan Type: PDP
Detailed Monthly costs for CVS Pharmacy #
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Initial Coverage Level $47.00 $119.12
Besylate/Atorvastatin Calcium
TAB 1020MG
Bupropion Hcl TAB 300MG XL Initial Coverage Level $25.49 $25.49
Levothyroxine Sodium TAB 100MCG Initial Coverage Level $10.00 $10.54
Drug Premium NA $39.60 n/a
MONTH 1 TOTAL $122.09 $155.15
2 MONTH 2 TOTAL $122.09 $155.15
3 MONTH 3 TOTAL $122.09 $155.15
If you get monthly
4 MONTH 4 TOTAL $122.09 $155.15
refills at CVS,
5 MONTH 5 TOTAL $122.09 $155.15
6 your annual costs MONTH 6 TOTAL $122.09 $155.15
7 in the First Health MONTH 7 TOTAL $122.09 $155.15
8 Part D Value Plus MONTH 8 TOTAL $122.09 $155.15
9 plan are $1,465. MONTH 9 TOTAL $122.09 $155.15
10 MONTH 10 TOTAL $122.09 $155.15
11 MONTH 11 TOTAL $122.09 $155.15
12 MONTH 12 TOTAL $122.09 $155.15
Aetna Medicare Rx Saver (PDP)
(S5810 045) Plan Type: PDP
Detailed Monthly costs for CVS Pharmacy #
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Deductible $119.12 $119.12
Besylate/Atorvastatin Calcium
TAB 1020MG
Bupropion Hcl TAB 300MG XL Deductible $25.49 $25.49
Levothyroxine Sodium TAB 100MCG Deductible $7.00 $7.47
Drug Premium NA $42.80 n/a
MONTH 1 TOTAL $194.41 $152.08
2 MONTH 2 TOTAL $194.41 $152.08
3 MONTH 3 TOTAL $194.41 $152.08
If you get monthly
4 MONTH 4 TOTAL $110.29 $152.08
refills at CVS, your
5 MONTH 5 TOTAL $110.29 $152.08
annual costs in the
6 MONTH 6 TOTAL $110.29 $152.08
7 Aetna Medicare MONTH 7 TOTAL $110.29 $152.08
8 Rx Saver plan are MONTH 8 TOTAL $110.29 $152.08
9 $1,576. MONTH 9 TOTAL $110.29 $152.08
10 MONTH 10 TOTAL $110.29 $152.08
11 MONTH 11 TOTAL $110.29 $152.08
12 MONTH 12 TOTAL $110.29 $152.08
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