Page 97 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details
CVS Pharmacy #10434 Walgreens Mail Order Pharmacy

CVS Pharmacy #10434 - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Carvedilol TAB 25MG Every 1
$3.45 $3.45 $1.52 $3.35
Month
Diltiazem Hcl Sr CAP 240MG/24 Every 1
$6.67 $6.67 $2.93 $3.35
Month
Metformin Hcl TAB 1000MG Every 1
$2.90 $2.90 $1.28 $2.90
Month
Multaq TAB 400MG Every 1
$611.60 $40.00 $214.06 $30.58
Month
Olmesartan
Medoxomil/Hydrochlorothiazide TAB $63.60 Every 1 $17.17 $27.98 $3.35
Month
40-12.5
Omega-3-Acid Ethyl Esters CAP 1GM Every 1
$83.13 $22.45 $36.58 $4.16
Month
Potassium Chloride Cr Every 1
$12.22 $10.00 $5.38 $3.35
(Microencapsulated) TAB 10MEQ CR Month
Pravastatin Sodium TAB 10MG Every 1
$2.15 $2.15 $0.95 $2.15
Month
MONTHLY TOTALS: $785.72 $104.79 $290.68 $53.19

Estimated Monthly Drug Costs

CVS Pharmacy #10434 Walgreens 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 N/A $216 $216

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.

Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription drug
coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its coverage
of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic drugs as
well. The drugs eligible for the brand discount or the additional generic savings may change based on the information
we have available.
Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY AUTHORIZATION LIMITS [?] THERAPY
STATUS) [?] [?] [?]
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