Page 83 - Evaluation for 2018

12/23/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy # Walmart Pharmacy 10-2865 Mail Order Pharmacy

Mail Order Pharmacy
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 $98.96 Every 3 $9.00 $9.00 $43.54 $4.95
Months
20-12.5
Lisinopril TAB 10MG Every 3
$4.23 $0.00 $0.00 $1.86 $3.35
Months
Simvastatin TAB 20MG Every 3
$4.96 $0.00 $0.00 $2.18 $3.35
Months
MONTHLY TOTALS: $108.15 $9.00 $9.00 $47.58 $11.65

Estimated Monthly Drug Costs

CVS Pharmacy # Walmart Pharmacy 10-2865 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$22 $13 $13 $22 $13 $13 $22 $13 $13 $22 $13 $13

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
20-12.5 Tier 2: Generic
Lisinopril TAB 10MG
Tier 1: Preferred Generic
Simvastatin TAB 20MG
Tier 1: Preferred Generic
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Pharmacy & Mail Order Information

Mail Order is available.
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S7694&plnid=030&sgmntid=0 2/3