Page 81 - Cover Letter and Evaluation for Kirk Schmidt

10/31/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy # Walgreens Mail Order Pharmacy

CVS Pharmacy # - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Initial Coverage Coverage Catastrophic
DRUG Frequency Level[?] Gap[?] Coverage[?]
Advair Diskus AER Every 2
250/50 $365.77 Months $84.00 $128.02 $18.29
Atorvastatin Calcium Every 1
TAB 20MG $5.30 Month $3.00 $2.33 $3.35
Valsartan TAB 320MG Every 1
$25.12 $13.00 $11.05 $3.35
Month
MONTHLY TOTALS: $396.19 $100.00 $141.40 $24.99

Estimated Monthly Drug Costs

CVS Pharmacy # Walgreens Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$128 $44 $128 $44 $128 $44 $128 $44 $128 $44 $128 $44

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 [?]
Advair Diskus AER 250/50
Tier 3: Preferred Brand Yes
Atorvastatin Calcium TAB 20MG
Tier 1: Preferred Generic
Valsartan TAB 320MG
Tier 2: Generic
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
6 network pharmacies in your ZIP code
Pharmacy Network [?]
Preferred pharmacy network available [?]

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