Page 138 - Cover Letter & Evaluation for Carol Evans

6/6/2018 Your Plan Results
Retail $30.00 Annual Drug Deductible: All Your Drugs on Formulary Enroll
Annual: $360.00 $405 :N/A
4 out of 5 stars
Mail Order Drug Copay/ Coinsurance: Drug Restrictions: N/A
Annual: N/A $1 - $18, 25% - 45%
MTM Program : Yes

Symphonix Value Rx (PDP) (S0522-044-0)
Organization: UnitedHealthcare
Estimated Annual Monthly Deductibles: [?] and Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Drug Copay [?] / Restrictions [?] and Rating: [?]
[?] Coinsurance: [?] Other Programs:
Retail $31.30 Annual Drug Deductible: All Your Drugs on Formulary Enroll
Annual: $375.60 $405 :N/A
3 out of 5 stars
Mail Order Drug Copay/ Coinsurance: Drug Restrictions: N/A
Annual: N/A $1 - $28, 25% - 29%
MTM Program : Yes

Cigna-HealthSpring Rx Secure (PDP) (S5617-138-0)
Organization: Cigna-HealthSpring Rx
Estimated Annual Monthly Deductibles: [?] and Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Drug Copay [?] / Restrictions [?] and Rating: [?]
[?] Coinsurance: [?] Other Programs:
Retail $31.40 Annual Drug Deductible: All Your Drugs on Formulary Enroll
Annual: $376.80 $405 :N/A
2 out of 5 stars
Mail Order Drug Copay/ Coinsurance: Drug Restrictions: N/A
Annual: N/A $2 - $34, 25% - 40%
MTM Program : Yes

Humana Preferred Rx Plan (PDP) (S5884-146-0)
Organization: Humana Insurance Company
Estimated Annual Monthly Deductibles: [?] and Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Drug Copay [?] / Restrictions [?] and Rating: [?]
[?] Coinsurance: [?] Other Programs:
Retail $31.50 Annual Drug Deductible: All Your Drugs on Formulary Enroll
Annual: $378.00 $405 :N/A
3.5 out of 5
Mail Order Drug Copay/ Coinsurance: Drug Restrictions: N/A stars
Annual: N/A $0 - $1, 20% - 35%
MTM Program : Yes

Notes:
Your costs may be different depending on your Part B premium, any Part D penalty that may apply, and whether you qualify for
Extra Help from Medicare paying your drug costs.

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