Page 70 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 53151
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 5933054208
and more coverage and star ratings.
Password Date: 10/11/2018
Important Coverage Information

You are now viewing 2019 plan data. View 2018 plan data.
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A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Premier P.O. Box 14088 Overall Star Rating: [?] Enrollment begins
Lexington, KY 40512 October 15, 2018
Plan (PPO)
(H5521-150-0) Members: 4 out of 5 stars
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)

Plan Type: Local Preferred Non Members:
Provider Organization 1-833-859-6031
711 (TTY/TDD)

Fixed Costs

Monthly Drug Plan Premium [?] $17.00

Monthly Health Plan Premium [?] $7.00

Annual Drug Deductible [?] $95.00

Medicare costs at a glance

Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs

Full Year Cost (based on January enrollment) [?]
CVS Pharmacy #16654 $204.00
Walgreens #7259 $1,166.04
Mail Order Pharmacy $204.00
Lower your drug costs

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=150&sgmntid=0#plan_drug_cost 1/3