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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 Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Initial Coverage Level $141.00 $355.36
Besylate/Atorvastatin Calcium
TAB 10­20MG
Bupropion Hcl TAB 300MG XL Initial Coverage Level $74.47 $74.47
Levothyroxine Sodium TAB 100MCG Initial Coverage Level $6.00 $27.76
Drug Premium NA $39.60 n/a
MONTH 1 TOTAL $261.07 $457.59
2 MONTH 2 TOTAL $39.60 $0.00
If you get mail-
3 MONTH 3 TOTAL $39.60 $0.00
order refills,
4 MONTH 4 TOTAL $261.07 $457.59
your annual
5 MONTH 5 TOTAL $39.60 $0.00
6 costs in the First MONTH 6 TOTAL $39.60 $0.00
7 Health Part D MONTH 7 TOTAL $261.07 $457.59
8 Value Plus plan MONTH 8 TOTAL $39.60 $0.00
9 will be $1,361. MONTH 9 TOTAL $39.60 $0.00
10 MONTH 10 TOTAL $261.07 $457.59
11 MONTH 11 TOTAL $39.60 $0.00
12 MONTH 12 TOTAL $39.60 $0.00
Aetna Medicare Rx Saver (PDP)
(S5810 ­ 045) Plan Type: PDP
Detailed Monthly costs for Mail Order Pharmacy
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Deductible \ Initial Coverage Level $355.36 $355.36
Besylate/Atorvastatin Calcium
TAB 10­20MG
Bupropion Hcl TAB 300MG XL Deductible $74.47 $74.47
Levothyroxine Sodium TAB 100MCG Deductible $3.00 $27.76
Drug Premium NA $42.80 n/a
MONTH 1 TOTAL $475.63 $457.59
2 MONTH 2 TOTAL $42.80 $0.00
3 MONTH 3 TOTAL $42.80 $0.00
4 If you get MONTH 4 TOTAL $225.27 $457.59
5 MONTH 5 TOTAL $42.80 $0.00
mail-order
6 MONTH 6 TOTAL $42.80 $0.00
refills, your
7 MONTH 7 TOTAL $225.27 $457.59
annual costs
8 MONTH 8 TOTAL $42.80 $0.00
in the Aetna
9 MONTH 9 TOTAL $42.80 $0.00
Medicare Rx
10 MONTH 10 TOTAL $225.27 $457.59
11 Saver Plan MONTH 11 TOTAL $42.80 $0.00
12 are $1,494. MONTH 12 TOTAL $42.80 $0.00

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