Page 98 - Cover Letter and Evaluation for Mike Peaseley
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11/17/2017 Your Medicare Health Plan Details
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Your Plan Details
Zip Code: 98499
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 6951340928
and more coverage and star ratings.
Password Date: 11/16/2017
Important Coverage Information
Symbols
A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or
instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Vision Coverage Some Hearing Coverage
* Estimated
Aetna Medicare Value Plan P.O. Box 14088 Overall Star Rating: [?] Enroll
Lexington, KY 40512
(HMO)
(H3931-126-0) Members: 3.5 out of 5 stars
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)
Plan Type: Non Members:
1-855-338-7027
711 (TTY/TDD)
Fixed Costs
Monthly Drug Plan Premium [?] $0.00
Monthly Health Plan Premium [?] Lowest prices at $0.00
CVS, which is a
Annual Drug Deductible [?] preferred $0.00
Medicare costs at a glance pharmacy in this
plan
Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs
Full Year Cost (based on January enrollment) [?]
Walgreens #3514 $1,471.56
CVS Pharmacy # $834.52
Mail Order Pharmacy $856.42
Lower your drug costs
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3931&plnid=126&sgmntid=0#plan_drug_cost 1/4