Page 97 - Cover letter and evaluation for Jack Hosier

11/14/2017 Your Medicare Health Plan Details
Walmart Pharmacy 10-3477 CVS Pharmacy #
Walmart Pharmacy 10-3477 - 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[?]
Allopurinol TAB 300MG Every 1
$15.00 $15.00 $15.00 $6.60 7 $3.35
Month
Amlodipine
Besylate/Valsartan TAB 10- $20.00 Every 1 $20.00 $20.00 $8.80 7 $3.35
Month
320MG
Atorvastatin Calcium TAB Every 1
20MG $20.00 Month $20.00 $20.00 $8.80 7 $3.35
Omeprazole CAP 20MG Every 1
$20.00 $20.00 $20.00 $8.80 7 $3.35
Month
MONTHLY TOTALS: $75.00 $75.00 $75.00 $33.00 $13.40
7 The price displayed for this drug may be lower than what you would typically pay during this period because of additional gap coverage offered by this plan.

Estimated Monthly Drug Costs

Walmart Pharmacy 10-3477 CVS Pharmacy #

Monthly Costs (based on January enrollment)
$95 $95 $95 $95 $95 $95 $95 $95 $95 $95 $95 $95

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 1: Preferred Generic
Amlodipine Besylate/Valsartan TAB 10- Yes
320MG Tier 2: Generic
Atorvastatin Calcium TAB 20MG
Tier 2: Generic Yes
Omeprazole CAP 20MG
Tier 2: Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is not available.
Pharmacy Network [?]
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5810&plnid=295&sgmntid=0 2/3