Page 81 - Evaluation for Dirk Huybrechts

9/12/2017 Your Medicare Health Plan Details
CVS Pharmacy - 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[?]
Pravastatin Sodium Every 1
TAB 20MG $10.70 Month $10.70 $10.70 $5.46 $3.30
Zolpidem Tartrate Every 1
TAB 10MG $6.50 Month $6.50 $6.50 $3.32 $3.30

MONTHLY TOTALS: $17.20 $17.20 $17.20 $8.78 $6.60

Estimated Monthly Drug Costs

CVS Pharmacy Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A N/A N/A N/A N/A N/A N/A N/A N/A $34 $34 $34

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 [?]
Pravastatin Sodium TAB 20MG
Tier 2: Generic Yes
Zolpidem Tartrate TAB 10MG
Tier 2: Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary
Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
5 network pharmacies in your ZIP code
Preferred pharmacy network available [?]

Drug List
Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY

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