Page 66 - Cover Letter and Evaluation for Barbara Lesswing

11/18/2017 Your Plan Results
Humana Walmart Rx Plan (PDP) (S5552-005-0)
Organization: Humana Insurance Company of New York
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $20.40 Annual Drug Deductible: All Your Drugs on Enroll
$405 Formulary :Yes
Pharmacy Status: 3.5 out of 5 stars
Standard Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $1 - $4, 25% - 35% Lower Your Drug Costs
Annual: $2,451 MTM Program : Yes
Mail Order
Annual: $1,976
Humana Enhanced (PDP) (S5552-003-0)
Organization: Humana Insurance Company of New York
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $80.50 Annual Drug Deductible: $0 All Your Drugs on Enroll
Formulary :Yes
Pharmacy Status: Drug Copay/ Coinsurance: 3.5 out of 5 stars
Standard Cost- $3 - $42, 33% - 44% Drug Restrictions: Yes
Sharing Lower Your Drug Costs
Annual: $2,501 MTM Program : Yes

Mail Order
Annual: $2,354
EnvisionRxPlus (PDP) (S7694-003-0)
Organization: EnvisionRx Plus
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $12.60 Annual Drug Deductible: All Your Drugs on Enroll
$300 Formulary :No
Pharmacy Status: 3 out of 5 stars
Preferred Cost- Drug Copay/ Coinsurance: Drug Restrictions: Yes
Sharing $1 - $29, 27% - 38% Lower Your Drug Costs
Annual: $2,503 MTM Program : Yes
Mail Order
Annual: $2,430
SilverScript Choice (PDP) (S5601-006-0)
Organization: SilverScript
Estimated Annual Monthly Deductibles: [?] and Drug Drug Coverage [?] , Drug Overall Star
Drug Costs: [?] Premium: Copay [?] / Coinsurance: Restrictions [?] and Other Rating: [?]
[?] [?] Programs:
Retail $29.80 Annual Drug Deductible: $0 All Your Drugs on Enroll
Formulary :No
Pharmacy Status: Drug Copay/ Coinsurance: 4 out of 5 stars
Preferred Cost- $3 - $40, 33% - 44% Drug Restrictions: Yes
Sharing Lower Your Drug Costs
Annual: $2,520 MTM Program : Yes
Mail Order
Annual: $2,379

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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