Page 71 - Evaluation for 2018

1/4/2018 Your Medicare Health Plan Details
CVS Pharmacy # Walmart Pharmacy 10-2865 Mail Order Pharmacy
CVS Pharmacy # - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Benazepril
Hcl/Hydrochlorothiazide TAB $44.42 Every 1 $2.00 $2.00 $19.54 $3.35
Month
20-12.5
Lisinopril TAB 10MG Every 1
$2.81 $2.00 $2.00 $1.24 $2.81
Month
Simvastatin TAB 20MG Every 1
$2.94 $2.00 $2.00 $1.29 $2.94
Month
MONTHLY TOTALS: $50.17 $6.00 $6.00 $22.07 $9.10

Estimated Monthly Drug Costs

CVS Pharmacy # Walmart Pharmacy 10-2865 Mail Order Pharmacy

Monthly Costs for the Rest of the Year (based on enrollment today)
N/A $23 $23 $23 $23 $23 $23 $23 $23 $23 $23 $23

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
[?] [?] [?] [?]
Benazepril Hcl/Hydrochlorothiazide TAB Yes
20-12.5 Tier 1: Preferred Generic
Lisinopril TAB 10MG
Tier 1: Preferred Generic Yes
Simvastatin TAB 20MG
Tier 1: Preferred Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary
Pharmacy & Mail Order Information

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

Drug List
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H1286&plnid=002&sgmntid=0 2/3