Page 39 - APPENDICES for Stephen Spero
P. 39
$0
Health deductible
$435.00 Your metformin prescription is
Drug deductible not covered by the plans below
this line. That is the reason the
Rx drug costs for the last 5
$900 In-network Maximum you pay for health services
months in these plans are more
than 4 times higher than the
costs for the plans above the
View More Information line. See cover letter for
explanation.
Blue Shield 65 Plus (HMO)
Blue Shield of California | Plan ID: H0504-028-0
Star rating:
MONTHLY PREMIUM
$0.00
Includes: Health & drug coverage
Doesn't include: $144.60 Standard Part B premium
YEARLY DRUG & PREMIUM COST
$4,648.58
Retail pharmacy: Estimated total drug + premium cost
Doesn't include: Health costs
OTHER COSTS
$0
Health deductible
$0.00
Drug deductible
$3,399 In-network Maximum you pay for health services
