Page 119 - Cover Letter and Evaluation for Anne Ellzey

11/8/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

HEB Pharmacy CVS Pharmacy Mail Order Pharmacy

HEB Pharmacy - Preferred Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST Refill Deductible[?] Initial Coverage Catastrophic
OF DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Alprazolam TAB 0.25MG Every 2
$2.35 $2.35 $2.35 $1.03 $2.35
Months
Aripiprazole TAB 15MG Every 2
$340.12 $340.12 $125.84 $149.65 $17.01
Months
Cyclobenzaprine Hcl TAB 5MG Every 2
$88.59 $88.59 $60.00 $38.98 $4.43
Months
Exemestane TAB 25MG Every 1
$413.25 $413.25 $152.90 $181.83 $20.66
Month
Hydrocodone/Acetaminophen Every 2
$46.60 $46.60 $46.60 $20.50 $3.35
TAB 5-300MG Months
Lamotrigine TAB 150MG Every 1
$2.48 $2.00 $2.00 $1.09 $2.48
Month
Losartan Potassium TAB Every 1
25MG $1.49 Month $1.00 $1.00 $0.66 $1.49
Lyrica CAP 50MG Every 1
$633.01 $633.01 $30.00 $221.55 $31.65
Month
Meloxicam TAB 7.5MG Every 2
$1.78 $1.78 $1.78 $0.78 $1.78
Months
Sumatriptan SPR 20MG/ACT Every 2
$3.87 $3.87 $3.87 $1.70 $3.35
Months
Venlafaxine Hcl TAB 150MG Every 1
$31.04 $31.04 $30.00 $13.66 $3.35
ER Month
Zolpidem Tartrate TAB 10MG Every 1
$2.02 $2.00 $2.00 $0.89 $2.02
Month
MONTHLY TOTALS: $1,566.60 $1,565.61 $458.34 $632.32 $93.92

Estimated Monthly Drug Costs

HEB Pharmacy CVS Pharmacy Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$644 $242 $646 $444 $657 $444 $645 $86 $118 $86 $118 $86

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.
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