Page 87 - Evaluation for Dirk Huybrechts

9/12/2017 Your Medicare Health Plan Details
Catastrophic
Coverage
SELECTED DRUGS FULL COST OF Refill Initial CoverageDrug Costs During Coverage Levels
DRUG Frequency Level[?] Gap[?] Coverage[?]
Pravastatin Sodium FULL COST OF Refill Initial Coverage Coverage Catastrophic
SELECTED DRUGS
Every 1
$10.03 Frequency Level[?] $5.00 7 $3.30
$5.00
Coverage[?]
Gap[?]
DRUG
TAB 20MG Month
Zolpidem Tartrate TAB Every 1
$7.05 $7.05 $7.05 $3.30
10MG Month
MONTHLY TOTALS: $17.08 $12.05 $12.05 $6.60
7 The price displayed for this drug may be lower than what you would typically pay during this period because of additional gap coverage offered by this plan.
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 $25 $25 $25

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 1: Preferred Generic
Zolpidem Tartrate TAB 10MG
Tier 2: Generic Yes Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

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

Drug List

Add/Edit Drugs

MEDICINE NAME QUANTITY FREQUENCY & GENERIC OPTIONS ACTION
PHARMACY
PRAVASTATIN SODIUM TAB 20MG
30 Every 1 Month Already Generic Change dose Add
Retail Pharmacy Remove

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