Page 79 - Cover letter and evaluation for Linda Hosier

11/15/2017 Monthly Cost Chart
Monthly Cost Chart

Show monthly cost chart for:
Monthly Cost Chart
CVS Pharmacy # These are your month-by-month
Walmart Pharmacy 10-3477 costs when you get mail-order
Mail Order Pharmacy refills.
Humana Walmart Rx Plan (PDP)
(S5884 - 178) Plan Type: PDP
Detailed Monthly costs for Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Atorvastatin Calcium TAB Deductible $8.00 $19.90
1 20MG
Estradiol DIS 0.0375MG (Twice Weekly Patch) Deductible $97.48 $97.48
Progesterone Micronized CAP 100MG Deductible $84.09 $84.09
Drug Premium NA $20.40 n/a
MONTH 1 TOTAL $209.97 $201.47
2 MONTH 2 TOTAL $20.40 $0.00
3 MONTH 3 TOTAL $20.40 $0.00
4 MONTH 4 TOTAL $209.97 $201.47
5 MONTH 5 TOTAL $20.40 $0.00
6 MONTH 6 TOTAL $20.40 $0.00
7 MONTH 7 TOTAL $111.14 $201.47
8 MONTH 8 TOTAL $20.40 $0.00
9 MONTH 9 TOTAL $20.40 $0.00
10 MONTH 10 TOTAL $75.97 $201.47
11 MONTH 11 TOTAL $20.40 $0.00
12 MONTH 12 TOTAL $20.40 $0.00

w31

https://plancompare.medicare.gov/pfdn/Popup/MonthlyCostChart?PlanFinderDRxIntegrationId=5f8d9516abe34b3eb65c72640575ddb0879641799830… 1/1