Page 59 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Plan Results
Humana Gold Plus H5619-100 (HMO) (H5619-100-0)
Organization: Arcadian Health Plan, Inc.
Estimated Monthly Deductibles Health Drug Coverage Estimated Overall Star
Annual Drug Premium: [?] and Drug Benefits: [?] [?] , Drug Annual Rating: [?]
Costs: [?] [?] Copay [?] / Restrictions [?] Health and
Coinsurance: and Other Drug
[?] Programs: Costs: [?]
Retail $17.00 Annual Drug Doctor Choice: All Your Drugs on $5,320 Enroll
Deductible: Plan Doctors Formulary :Yes
Pharmacy Drug: $0.00 $125 for Most 4 out of 5
Status: Health: Services Drug Restrictions: stars
Preferred Cost- $17.00 Health Plan Yes
Sharing Deductible: $0 Out of Pocket Lower Your Drug
Part B Drug Copay/ Spending Costs
Annual: $1,469 Premium Coinsurance: $2 Limit: $6,700
Reduction - $100, 30% In-network MTM Program :
Mail Order :No Yes
Annual: $944

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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