Page 56 - Cover Letter & Evaluation for Patricia Letizia

10/10/2018 Your Plan Results
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Star
Costs: [?] [?] Copay [?] / Restrictions [?] Health and Rating: [?]
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $0.00 Annual Drug Doctor All Your Drugs on $3,940 Enrollment begins
Deductible: Choice: Any Formulary :Yes October 15, 2018
Pharmacy Drug: $0.00 $275 Doctor 4 out of 5
Status: Health: Drug Restrictions: stars
Preferred Cost- $0.00 Health Plan Out of Pocket Yes
Sharing Deductible: $0 Spending Lower Your
Part B Drug Copay/ Limit: $5,900 Drug Costs
Annual: $392 Premium Coinsurance: In and Out-
Reduction $2 - $84, 27% of-network MTM Program :
Mail Order :No $5,900 In- Yes
Annual: $306 network

Assurance Rx (HMO-POS) (H5211-007-0)
Organization: Security Health Plan of Wisconsin, Inc.
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Star
Costs: [?] [?] Copay [?] / Restrictions [?] Health and Rating: [?]
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $0.00 Annual Drug Doctor All Your Drugs on $4,030 Enrollment begins
Deductible: Choice: Plan Formulary :Yes October 15, 2018
Pharmacy Drug: $0.00 $330 Doctors Only 4.5 out of 5
Status: Health: (some Drug Restrictions: stars
Standard Cost- $0.00 Health Plan exceptions) Yes
Sharing Deductible: $0 Lower Your
Part B Drug Copay/ Out of Pocket Drug Costs
Annual: $429 Premium Coinsurance: Spending
Reduction $0 - $100, 26% Limit: $7,500 MTM Program :
Mail Order :No In and Out- Yes
Annual: $393 of-network
$6,500 In-
network
$7,500 Out-
of-network

Humana Gold Plus H6622-034 (HMO) (H6622-034-0)
Organization: Humana
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Star
Costs: [?] [?] Copay [?] / Restrictions [?] Health and Rating: [?]
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $0.00 Annual Drug Doctor All Your Drugs on $3,500 Enrollment begins
Deductible: Choice: Plan Formulary :Yes October 15, 2018
Pharmacy Drug: $0.00 $300 Doctors for 4 out of 5
Status: Health: Most Services Drug Restrictions: stars
Preferred Cost- $0.00 Health Plan Yes
Sharing Deductible: $0 Out of Pocket Lower Your
Part B Drug Copay/ Spending Drug Costs
Annual: $474 Premium Coinsurance: Limit: $4,500
Reduction $6 - $100, 27% In-network MTM Program :
Mail Order :No Yes
Annual: $0
Humana Gold Plus H6622-040 (HMO) (H6622-040-0)
Organization: Humana
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Star
Costs: [?] [?] Copay [?] / Restrictions [?] Health and Rating: [?]
Coinsurance: and Other Drug
[?] Programs: Costs: [?]

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