Page 89 - 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

Aetna Medicare Choice Plan (PPO)
(H5521 - 125) Plan Type: Local Preferred Provider Organization

Detailed Monthly costs for CVS Pharmacy
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MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Pravastatin Sodium TAB 20MG Initial Coverage Level $5.00 $10.03
1 Zolpidem Tartrate TAB 10MG Initial Coverage Level $7.05 $7.05
Drug Premium NA $12.60 n/a
MONTH 1 TOTAL $24.65 $17.08
2 MONTH 2 TOTAL $24.65 $17.08
3 In 2017 the estimated MONTH 3 TOTAL $24.65 $17.08
4 annual costs for your two MONTH 4 TOTAL $24.65 $17.08
5 Rx drugs if you get retail MONTH 5 TOTAL $24.65 $17.08
6 reflls at CVS is $295.80, MONTH 6 TOTAL $24.65 $17.08
7 including premiums and MONTH 7 TOTAL $24.65 $17.08
8 co-payments. For the last MONTH 8 TOTAL $24.65 $17.08
9 three months of 2017, the MONTH 9 TOTAL $24.65 $17.08
10 est. cost is $73.95. MONTH 10 TOTAL $24.65 $17.08
11 MONTH 11 TOTAL $24.65 $17.08
12 MONTH 12 TOTAL $24.65 $17.08

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