Page 89 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens #3514 CVS Pharmacy # Mail Order Pharmacy

Walgreens #3514 - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Initial Coverage Coverage Catastrophic
DRUG Frequency Level[?] Gap[?] Coverage[?]
Atorvastatin Calcium Every 1
TAB 40MG $8.12 Month $7.00 $3.57 $3.35
Brilinta TAB 90MG Every 1
$337.91 $47.00 $118.27 $16.90
Month
Lisinopril TAB 2.5MG Every 1
$1.15 $1.15 $0.51 $1.15
Month
Metoprolol Tartrate TAB Every 1
$1.53 $1.53 $0.67 $1.53
25MG Month
Nitroglycerin SUB Every 1
$15.73 $15.73 $6.92 $3.35
0.4MG Month
Omeprazole CAP 20MG Every 1
$2.91 $2.91 $1.28 $2.91
Month
Sertraline Hcl TAB Every 2
100MG $3.12 Months $3.12 $1.37 $3.12

MONTHLY TOTALS: $370.47 $78.44 $132.59 $32.31

Estimated Monthly Drug Costs

Walgreens #3514 CVS Pharmacy # Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$109 $106 $109 $106 $109 $106 $109 $106 $109 $106 $199 $162

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 40MG
Tier 1: Preferred Generic
Brilinta TAB 90MG
Tier 3: Preferred Brand
Lisinopril TAB 2.5MG
Tier 1: Preferred Generic

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