Page 77 - Cover letter and evaluation for Linda Hosier

11/15/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy # Walmart Pharmacy 10-3477 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[?]
Atorvastatin Calcium TAB Every 1
20MG $7.40 Month $7.40 $7.40 $3.26 $3.35
Estradiol DIS 0.0375MG Every 2
(Twice Weekly Patch) 16 $95.68 Months $95.68 $95.68 $42.10 $4.78
Progesterone Micronized CAP Every 1
$21.03 $21.03 $5.26 $9.25 $3.35
100MG Month
MONTHLY TOTALS: $124.11 $124.11 $108.34 $54.61 $11.48

16 This drug is covered by the plan; however, the plan does not offer a benefit for the frequency and pharmacy type you selected. Therefore, the cost displayed
is an estimate of the full cost of the drug for the frequency entered.
Estimated Monthly Drug Costs

CVS Pharmacy # Walmart Pharmacy 10-3477 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$145 $49 $145 $49 $145 $43 $129 $33 $129 $33 $129 $33

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
[?] [?] [?] [?]
Atorvastatin Calcium TAB 20MG
Tier 2: Generic Yes
Estradiol DIS 0.0375MG (Twice Weekly Tier 4: Non-Preferred
Patch) Yes
Drug
Progesterone Micronized CAP 100MG
Tier 3: Preferred Brand
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=S5884&plnid=178&sgmntid=0 2/3