Page 38 - Cover Letter and Evaluation for Chris Parlin

10/11/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens Walmart Pharmacy 10-5936 Mail Order Pharmacy

Walgreens - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Initial Coverage Coverage Catastrophic
OF DRUG Frequency Level[?] Gap[?] Coverage[?]
Allopurinol TAB 300MG Every 1
$10.20 $7.00 $4.49 $3.35
Month
Amlodipine Besylate TAB 5MG Every 1
$7.15 $3.00 $3.15 $3.35
Month
Atorvastatin Calcium TAB 20MG Every 1
$7.50 $3.00 $3.30 $3.35
Month
Januvia TAB 100MG Every 1
$398.01 $42.00 $139.30 $19.90
Month
Metformin Hcl TAB 500MG ER Every 1
$7.15 $3.00 $3.15 $3.35
Month
Valsartan/Hydrochlorothiazide Every 1
TAB 320-25MG $8.29 Month $3.00 $3.65 $3.35
MONTHLY TOTALS: $438.30 $61.00 $157.04 $36.65

Estimated Monthly Drug Costs

Walgreens Walmart Pharmacy 10-5936 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$139 $139 $139 $139 $139 $139 $139 $139 $207 $235 $235 $235

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.

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) AUTHORIZATION LIMITS THERAPY
[?] [?] [?] [?]
Allopurinol TAB 300MG
Tier 2: Generic
Amlodipine Besylate TAB 5MG
Tier 1: Preferred Generic
Atorvastatin Calcium TAB 20MG
Tier 1: Preferred Generic Yes
Januvia TAB 100MG
Tier 3: Preferred Brand Yes

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