Page 98 - Cover Letter and evaluation for Katherine Kensky

11/6/2017 Your Medicare Health Plan Comparison
All of your drugs are covered on the plan’s formulary. All of your drugs are covered on the plan’s formulary.
Alprazolam TAB 0.5MG Alprazolam TAB 0.5MG
Quantity Limit Quantity Limit

Tier 2: Generic Tier 3: Preferred Brand
Duloxetine Hcl CAP 30MG
Duloxetine Hcl CAP 30MG
Quantity Limit
Quantity Limit
Tier 3: Preferred Brand
Tier 3: Preferred Brand
Estradiol DIS 0.0375MG (Twice Weekly Patch)
Estradiol DIS 0.0375MG (Twice Weekly Patch)
Prior Authorization
Quantity Limit
Quantity Limit
Tier 3: Preferred Brand Tier 4: Non-Preferred Drug
Progesterone Micronized CAP 100MG Progesterone Micronized CAP 100MG
No restrictions No restrictions

Tier 3: Preferred Brand Tier 3: Preferred Brand
Zolpidem Tartrate TAB 5MG Zolpidem Tartrate TAB 5MG
Prior Authorization
Quantity Limit
Quantity Limit
Tier 2: Generic
Tier 2: Generic

Print My Drug List Print Comparison Report

Pharmacy & Mail Order Information

Mail Order is available. Mail Order is available.
Pharmacy Network Pharmacy Network
1 network pharmacies in your ZIP code 1 network pharmacies in your ZIP code
Preferred pharmacy network available Preferred pharmacy network available

Drug List
Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY

Change dose Add
ALPRAZOLAM TAB 0.5MG 20 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
DULOXETINE HCL CAP 30MG 30 Every 1 Month Already Generic Remove
Retail Pharmacy

Change dose Add
ESTRADIOL DIS 0.0375MG 1 X 1 Box of 8 Every 1 Month Already Generic Remove
(TWICE WEEKLY PATCH) patches Retail Pharmacy

Change dose Add
PROGESTERONE MICRONIZED 60 Every 2 Months Already Generic Remove
CAP 100MG Retail Pharmacy
ZOLPIDEM TARTRATE TAB 5MG
https://www.medicare.gov/find-a-plan/results/planresults/plan-compare.aspx 3/4