Page 77 - Evaluation for Dirk Huybrechts

9/12/2017 Your Plan Results
Retail $67.50 Annual Drug Deductible: $0 All Your Drugs on Enroll
Formulary :Yes
Pharmacy Status: Drug Copay/ Coinsurance: 2.5 out of 5 stars
Standard Cost- $0 - $31, 33% - 45% Drug Restrictions: Yes
Sharing Lower Your Drug Costs
Cost as of Today: MTM Program : Yes
$204

Mail Order
Cost as of Today:
$203

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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