Page 90 - 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 Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Pravastatin Sodium TAB 20MG Initial Coverage Level $0.00 $11.08
1 Zolpidem Tartrate TAB 10MG Initial Coverage Level $5.35 $5.35
Drug Premium NA $12.60 n/a
MONTH 1 TOTAL $17.95 $16.43
2 MONTH 2 TOTAL $12.60 $0.00
3 Estimated annual MONTH 3 TOTAL $12.60 $0.00
4 cost of $172.60 in MONTH 4 TOTAL $17.95 $16.43
5 2017 if you get MONTH 5 TOTAL $12.60 $0.00
6 mail-order refills. MONTH 6 TOTAL $12.60 $0.00
7 MONTH 7 TOTAL $17.95 $16.43
8 MONTH 8 TOTAL $12.60 $0.00
9 MONTH 9 TOTAL $12.60 $0.00
10 MONTH 10 TOTAL $17.95 $16.43
11 MONTH 11 TOTAL $12.60 $0.00
12 MONTH 12 TOTAL $12.60 $0.00

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