Page 119 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details

Return to previous page
Your Plan Details

Zip Code: 92586
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: 3199691584
and more coverage and star ratings. Password Date: 10/09/2018

Important Coverage Information

You are now viewing 2019 plan data. View 2018 plan data.

Symbols
A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment will be
made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the enrollee is not
responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Choice P.O. Box 14088 Overall Star Rating: [?] Enrollment begins
Lexington, KY 40512 Coming Soon October 15, 2018
Plan (PPO)

(H5521-126-0) Members:
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)

Plan Type: Local Preferred Non Members:
Provider Organization 1-833-859-6031
711 (TTY/TDD)

Fixed Costs

Monthly Drug Plan Premium [?] $39.60

Monthly Health Plan Premium [?] $41.40

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

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

Full Year Cost (based on January enrollment) [?]
CVS Pharmacy #10434 $3,784.64
Walgreens $4,351.12
Mail Order Pharmacy $3,913.24
Lower your drug costs

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=126&sgmntid=0#plan_drug_cost 1/4