Page 86 - Evaluation for Dirk Huybrechts

9/12/2017 Your Medicare Health Plan Details

Cost and coverage details for the Rx
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drug coverage if you enroll in the Aetna
Your Plan Details Medicare Choice PPO Advantage plan.

Zip Code: 90049
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 0226651648
and more coverage and star ratings.
Password Date: 09/12/2017
Important Coverage Information

Symbols

Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Choice P.O. Box 14088 Overall Star Rating: [?] Enroll
Lexington, KY 40512
Plan (PPO)
(H5521-125-0) Members: 4 out of 5 stars
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)
Plan Type: Non Members:
1-855-338-7027
711 (TTY/TDD)

Fixed Costs

Monthly Drug Plan Premium [?] $12.60

Monthly Health Plan Premium [?] $60.40

Annual Drug Deductible [?] $0.00
Medicare costs at a glance

Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs

Cost For Rest of Year (based on enrollment today) [?]
CVS Pharmacy $73.95
Assumes you will
Mail Order Pharmacy $43.15 enroll effective
Lower your drug costs
October 1.

Estimated Full Cost the Plan Charges Medicare for Your Drugs

Drug Costs During Coverage Levels

CVS Pharmacy Mail Order Pharmacy

CVS Pharmacy - Standard Retail Cost Sharing
Drug Costs During Coverage Levels

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=125&sgmntid=0#plan_drug_cost 1/3