Page 83 - Evaluation for Dirk Huybrechts

9/12/2017 Monthly Cost Chart
Monthly Cost Chart

Show monthly cost chart for:
Monthly Cost Chart
CVS Pharmacy
Mail Order Pharmacy

Humana Walmart Rx Plan (PDP)
(S5884 - 178) Plan Type: PDP

Detailed Monthly costs for CVS Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Pravastatin Sodium TAB 20MG Deductible $10.70 $10.70
1 Zolpidem Tartrate TAB 10MG Deductible $6.50 $6.50
Drug Premium NA $17.00 n/a
MONTH 1 TOTAL $34.20 $17.20
2 MONTH 2 TOTAL $34.20 $17.20
Estimated annual
3 MONTH 3 TOTAL $34.20 $17.20
costs in 2017 of
4 MONTH 4 TOTAL $34.20 $17.20
$410.40 for retail
5 MONTH 5 TOTAL $34.20 $17.20
refills at CVS.
6 MONTH 6 TOTAL $34.20 $17.20
7 MONTH 7 TOTAL $34.20 $17.20
8 MONTH 8 TOTAL $34.20 $17.20
9 MONTH 9 TOTAL $34.20 $17.20
10 MONTH 10 TOTAL $34.20 $17.20
11 MONTH 11 TOTAL $34.20 $17.20
12 MONTH 12 TOTAL $34.20 $17.20

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