Page 54 - SAMPLE

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
BlueMedicare HMO LifeTime (HMO)
(H1026 ­ 040) Plan Type: HMO
Detailed Monthly costs for CVS Pharmacy #
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Initial Coverage Level $20.00 $161.23
Besylate/Atorvastatin Calcium
TAB 10­20MG
Bupropion Hcl TAB 300MG XL Initial Coverage Level $20.00 $22.42
Levothyroxine Sodium TAB 100MCG Initial Coverage Level $14.70 $14.70
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $54.70 $198.35
2 MONTH 2 TOTAL $54.70 $198.35
3 MONTH 3 TOTAL $54.70 $198.35
4 If you get monthly MONTH 4 TOTAL $54.70 $198.35
5 refills at CVS, MONTH 5 TOTAL $54.70 $198.35
6 your annual costs MONTH 6 TOTAL $54.70 $198.35
7 MONTH 7 TOTAL $54.70 $198.35
in the Blue
8 MONTH 8 TOTAL $54.70 $198.35
Medicare HMO
9 MONTH 9 TOTAL $54.70 $198.35
Lifetime plan will
10 MONTH 10 TOTAL $54.70 $198.35
be $656.
11 MONTH 11 TOTAL $54.70 $198.35
12 MONTH 12 TOTAL $54.70 $198.35
AARP MedicareComplete Choice Plan 2 (Regional PPO)
(R7444 ­ 003) Plan Type: Preferred Provider Organization
Detailed Monthly costs for CVS Pharmacy #
View All Months
MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
1 Amlodipine Deductible $2.00 $143.78
Besylate/Atorvastatin Calcium
TAB 10­20MG
Bupropion Hcl TAB 300MG XL Deductible $12.00 $22.73
Levothyroxine Sodium TAB 100MCG Deductible $2.00 $13.00
Drug Premium NA $0.00 n/a
MONTH 1 TOTAL $16.00 $179.51
If you get monthly
2 MONTH 2 TOTAL $16.00 $179.51
refills at CVS, your
3 MONTH 3 TOTAL $16.00 $179.51
4 annual costs in the MONTH 4 TOTAL $16.00 $179.51
5 AARP Medicare MONTH 5 TOTAL $16.00 $179.51
6 Complete Choice MONTH 6 TOTAL $16.00 $179.51
7 Plan 2 will be $192. MONTH 7 TOTAL $16.00 $179.51
8 MONTH 8 TOTAL $16.00 $179.51
9 MONTH 9 TOTAL $16.00 $179.51
10 MONTH 10 TOTAL $16.00 $179.51
11 MONTH 11 TOTAL $16.00 $179.51
12 MONTH 12 TOTAL $16.00 $179.51

w07

https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanFinderDRxIntegrationId=d541110155ee44f182e60a9b89383420857745533390&ContractYe… 1/1