Page 76 - Evaluation for Dirk Huybrechts

9/12/2017 Your Plan Results
Retail $33.40 Annual Drug Deductible: All Your Drugs on Enroll
$400 Formulary :Yes
Pharmacy Status: 3 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $1 - $21, 25% - 30% Lower Your Drug Costs
Cost as of Today: MTM Program : Yes
$142

Mail Order
Cost as of Today:
$125
WellCare Classic (PDP) (S4802-094-0)
Organization: WellCare
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $34.90 Annual Drug Deductible: All Your Drugs on Enroll
$400 Formulary :Yes
Pharmacy Status: 2.5 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $0 - $46, 25% - 48% Lower Your Drug Costs
Cost as of Today: MTM Program : Yes
$155
Mail Order
Cost as of Today:
$133
First Health Part D Value Plus (PDP) (S5768-155-0)
Organization: First Health Part D
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $42.30 Annual Drug Deductible: $0 All Your Drugs on Enroll
Formulary :Yes
Pharmacy Status: Drug Copay/ Coinsurance: 3.5 out of 5 stars
Standard Cost- $2 - $47, 33% - 50% Drug Restrictions: Yes
Sharing Lower Your Drug Costs
Cost as of Today: MTM Program : Yes
$179
Mail Order
Cost as of Today:
$138
Express Scripts Medicare - Value (PDP) (S5660-134-0)
Organization: Express Scripts Medicare
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $59.10 Annual Drug Deductible: All Your Drugs on Enroll
$400 Formulary :Yes
Pharmacy Status: 4 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $0 - $42, 25% - 48% Lower Your Drug Costs
Cost as of Today: MTM Program : Yes
$203
Mail Order
Cost as of Today:
$220
WellCare Extra (PDP) (S4802-128-0)
Organization: WellCare
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:

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