Page 84 - Evaluation for Dirk Huybrechts

9/12/2017 Monthly Cost Chart
Monthly Cost Chart

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Monthly Cost Chart
CVS Pharmacy
Mail Order Pharmacy

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

Detailed Monthly costs for Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Pravastatin Sodium TAB 20MG Deductible $8.00 $29.80
1 Zolpidem Tartrate TAB 10MG Deductible $8.00 $12.99
Drug Premium NA $17.00 n/a
MONTH 1 TOTAL $33.00 $42.79
2 Estimated annual MONTH 2 TOTAL $17.00 $0.00
3 costs in 2017 for MONTH 3 TOTAL $17.00 $0.00
4 mail-order refills is MONTH 4 TOTAL $33.00 $42.79
5 $268. MONTH 5 TOTAL $17.00 $0.00
6 MONTH 6 TOTAL $17.00 $0.00
7 MONTH 7 TOTAL $33.00 $42.79
8 MONTH 8 TOTAL $17.00 $0.00
9 MONTH 9 TOTAL $17.00 $0.00
10 MONTH 10 TOTAL $33.00 $42.79
11 MONTH 11 TOTAL $17.00 $0.00
12 MONTH 12 TOTAL $17.00 $0.00

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