Page 139 - Cover Letter and Evaluation for Gary Janke

10/8/2018 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

Walgreens #10191 CVS Pharmacy #17099 Mail Order Pharmacy

Walgreens #10191 - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Amlodipine Besylate TAB 5MG Every 1
$1.13 $1.13 $1.13 $0.42 $1.13
Month
Budesonide Suspension SUS Every 1
0.5MG/2 $240.24 Month $240.24 $120.12 $88.89 $12.01
Omeprazole CAP 40MG Every 1
$9.07 $3.00 $3.00 $3.36 $3.40
Month
Potassium Chloride CAP Every 1
$9.58 $9.58 $9.58 $3.54 $3.40
10MEQ CR Month
Ranitidine Hcl TAB 300MG Every 1
$7.92 $3.00 $3.00 $2.93 $3.40
Month
Symbicort AER 160-4.5 Every 1
$331.10 $331.10 $47.00 $82.78 $16.56
Month
Valsartan/Hydrochlorothiazide Every 1
TAB 160-12.5 $18.11 Month $3.00 $3.00 $6.70 $3.40
Ventolin HFA AER Every 12
$54.81 $54.81 $47.00 $13.70 $8.50
Months
MONTHLY TOTALS: $671.96 $645.86 $233.83 $202.32 $51.80

Estimated Monthly Drug Costs

Walgreens #10191 CVS Pharmacy #17099 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$488 $202 $202 $202 $202 $202 $209 $204 $204 $204 $204 $204

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.

Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription
drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its
coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic
drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the
information we have available.

Drug Coverage Information

Restrictions

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