Page 122 - Cover Letter and Evaluation for Anne Ellzey

11/8/2017 Monthly Cost Chart
Monthly Cost Chart

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Monthly Cost Chart
HEB Pharmacy In 2018, estimated
CVS Pharmacy 12-month costs are
Mail Order Pharmacy
$4,217 at HEB.
Aetna Medicare Rx Saver (PDP) Includes premiums,
(S5810 - 056) Plan Type: PDP deductible, and co-
pays
Detailed Monthly costs for HEB Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Alprazolam TAB 0.25MG Deductible $2.35 $2.35
1 Aripiprazole TAB 15MG Deductible \ Initial Coverage Level $257.37 $340.12
Cyclobenzaprine Hcl TAB 5MG Deductible $88.59 $88.59
Exemestane TAB 25MG Initial Coverage Level $152.90 $413.25
Hydrocodone/Acetaminophen TAB 5-300MG Deductible $46.60 $46.60
Lamotrigine TAB 150MG Deductible $2.00 $2.48
Losartan Potassium TAB 25MG Deductible $1.00 $1.49
Lyrica CAP 50MG Initial Coverage Level $30.00 $633.01
Meloxicam TAB 7.5MG Deductible $1.78 $1.78
Sumatriptan SPR 20MG/ACT Deductible $3.87 $3.87
Venlafaxine Hcl TAB 150MG ER Deductible $31.04 $31.04
Zolpidem Tartrate TAB 10MG Deductible $2.00 $2.02
Drug Premium NA $24.40 n/a
MONTH 1 TOTAL $643.90 $1,566.60
2 If you decide to enroll in Blue MONTH 2 TOTAL $242.30 $1,083.29
3 Cross Medicare Rx Plus Plan in MONTH 3 TOTAL $646.01 $1,566.60
4 December and then switch to the MONTH 4 TOTAL $444.08 $1,083.29
5 Aetna Medicare Rx Saver plan in MONTH 5 TOTAL $656.72 $1,566.60
6 December (to be effective MONTH 6 TOTAL $444.08 $1,083.29
7 1-1-18), you could save money. MONTH 7 TOTAL $645.25 $1,566.60
8 You would get mail-order refills MONTH 8 TOTAL $86.05 $1,083.29
9 in the Blue Cross plan, and MONTH 9 TOTAL $118.32 $1,566.60
10 those would last you through MONTH 10 TOTAL $86.05 $1,083.29
11 February. Starting in March, MONTH 11 TOTAL $118.32 $1,566.60
12 you'd use the Aetna plan for MONTH 12 TOTAL $86.05 $1,083.29
your refills.
Your 2018 costs in the Aetna
w31
plan if you get monthly refills
starting in March will be $4,062.
In January and February you
would pay only the $24.40
monthly premium, and then in
March your payment will be
$643.90, as shown above.

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