Page 84 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details

Estimated Full Cost the Plan Charges Medicare for Your Drugs

Drug Costs During Coverage Levels

CVS Pharmacy #16654 Walgreens #7259 Mail Order Pharmacy

CVS Pharmacy #16654 - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Amlodipine Besylate Every 1
$9.79 $4.00 $4.00 $3.62 $3.40
TAB 10MG Month
Lorazepam TAB Every 1
$12.49 $12.49 $12.49 $4.62 $3.40
0.5MG Month
Losartan Potassium Every 1
TAB 50MG $24.87 Month $4.00 $4.00 $9.20 $3.40
Nabumetone TAB Every 1
$10.22 $10.22 $10.22 $3.78 $3.40
500MG Month
Propranolol Hcl TAB Every 1
$9.76 $9.76 $9.76 $3.61 $3.40
10MG Month
MONTHLY TOTALS: $67.13 $40.47 $40.47 $24.83 $17.00

Estimated Monthly Drug Costs

CVS Pharmacy #16654 Walgreens #7259 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$40 $40 $40 $40 $40 $40 $40 $40 $40 $40 $40 $40

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Graph depicts an estimate of your monthly prescription drug costs, including any applicable premium for this plan.
Actual costs may vary.
View a more detailed explanation of these costs.

Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription
drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its
coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic
drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the
information we have available.

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Amlodipine Besylate TAB 10MG
Tier 1: Preferred Generic
Lorazepam TAB 0.5MG
Tier 3: Preferred Brand Yes

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5215&plnid=009&sgmntid=0#plan_drug_cost 2/3