Page 123 - Cover Letter and Evaluation for Anne Ellzey

11/8/2017 Monthly Cost Chart
Monthly Cost Chart

Show monthly cost chart for: Monthly costs in 2018 if you use mail-
Monthly Cost Chart
HEB Pharmacy order refills.
CVS Pharmacy
Mail Order Pharmacy
Aetna Medicare Rx Saver (PDP)
(S5810 - 056) Plan Type: PDP
Detailed Monthly costs for Mail Order Pharmacy
View All Months

MONTH ITEM COVERAGE LEVEL YOUR COST TOTAL DRUG COST
Alprazolam TAB 0.25MG Deductible $2.39 $2.39
1 Aripiprazole TAB 15MG Deductible \ Initial Coverage Level $213.99 $509.05
Cyclobenzaprine Hcl TAB 5MG Deductible $176.67 $176.67
Exemestane TAB 25MG Initial Coverage Level $457.88 $1,237.50
Hydrocodone/Acetaminophen TAB 5-300MG Deductible $66.75 $66.75
Lamotrigine TAB 150MG Deductible $5.18 $5.18
Losartan Potassium TAB 25MG Deductible $2.67 $2.67
Lyrica CAP 50MG Initial Coverage Level \ Coverage Gap $176.78 $1,896.78
Meloxicam TAB 7.5MG Deductible $1.55 $1.55
Sumatriptan SPR 20MG/ACT Deductible $4.69 $4.69
Venlafaxine Hcl TAB 150MG ER Deductible $90.88 $90.88
Zolpidem Tartrate TAB 10MG Deductible $3.82 $3.82
Drug Premium NA $24.40 n/a
MONTH 1 TOTAL $1,227.65 $3,997.93
2 MONTH 2 TOTAL $24.40 $0.00
3 MONTH 3 TOTAL $24.40 $0.00
4 MONTH 4 TOTAL $1,612.76 $3,997.93
5 MONTH 5 TOTAL $24.40 $0.00
6 MONTH 6 TOTAL $24.40 $0.00
7 MONTH 7 TOTAL $1,125.56 $3,997.93
8 MONTH 8 TOTAL $24.40 $0.00
9 MONTH 9 TOTAL $24.40 $0.00
10 MONTH 10 TOTAL $239.95 $3,997.93
11 MONTH 11 TOTAL $24.40 $0.00
12 MONTH 12 TOTAL $24.40 $0.00

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