Page 158 - Cover Letter and Evaluation for Gary Janke
P. 158
10/8/2018 Your Medicare Health Plan Details
Estimated Full Cost the Plan Charges Medicare for Your Drugs
Drug Costs During Coverage Levels
Walgreens #10191 CVS Pharmacy #17099 Mail Order Pharmacy
Mail Order Pharmacy
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Initial Coverage Coverage Catastrophic
OF DRUG Frequency Level[?] Gap[?] Coverage[?]
Amlodipine Besylate TAB 5MG Every 3
$12.42 $1.00 $1.00 7 $3.40
Months
Budesonide Suspension SUS Every 3
0.5MG/2 $252.74 Months $10.00 $93.51 $12.64
Omeprazole CAP 40MG Every 3
$45.00 $1.00 $1.00 7 $3.40
Months
Potassium Chloride CAP 10MEQ Every 3
$42.11 $10.00 $15.58 $3.40
CR Months
Ranitidine Hcl TAB 300MG Every 3
$31.72 $1.00 $1.00 7 $3.40
Months
Symbicort AER 160-4.5 Every 3
$859.88 $105.00 $214.97 $42.99
Months
Valsartan/Hydrochlorothiazide Every 3
$198.77 $1.00 $1.00 7 $9.94
TAB 160-12.5 Months
Ventolin HFA AER Every 12
$61.17 $61.17 $61.17 $61.17
Months
MONTHLY TOTALS: $1,503.81 $190.17 $389.23 $140.34
7 The price displayed for this drug may be lower than what you would typically pay during this period because of additional gap coverage offered by this plan.
Estimated Monthly Drug Costs
Walgreens #10191 CVS Pharmacy #17099 Mail Order Pharmacy
Monthly Costs (based on January enrollment)
$190 $0 $0 $129 $0 $0 $256 $0 $0 $328 $0 $0
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.
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H7917&plnid=032&sgmntid=0#plan_drug_cost 2/4
