Page 35 - Cover Letter and Evaluation for Anne Parlin

10/11/2017 Your Medicare Health Plan Details

Drug Costs During Coverage Levels

CVS Pharmacy Walmart Pharmacy 10-5936 Mail Order Pharmacy

CVS Pharmacy - Standard Retail Cost Sharing
Drug Costs During Coverage Levels
SELECTED DRUGS FULL COST OF Refill Deductible[?] Initial Coverage Catastrophic
DRUG Frequency Coverage Gap[?] Coverage[?]
Level[?]
Bupropion Hcl TAB Every 1
300MG XL $22.70 Month $22.70 $5.68 $9.99 $3.35
Sertraline Hcl TAB Every 1
50MG $6.50 Month $6.50 $6.50 $2.86 $3.35

MONTHLY TOTALS: $29.20 $29.20 $12.18 $12.85 $6.70

Estimated Monthly Drug Costs

CVS Pharmacy Walmart Pharmacy 10-5936 Mail Order Pharmacy

Monthly Costs (based on January enrollment)
$50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50

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.

Drug Coverage Information

Restrictions
SELECTED DRUGS TIER PRIOR QUANTITY STEP
(FORMULARY STATUS) [?] AUTHORIZATION [?] LIMITS [?] THERAPY [?]
Bupropion Hcl TAB 300MG XL
Tier 3: Preferred Brand Yes
Sertraline Hcl TAB 50MG
Tier 2: Generic Yes
Print My Drug List Print Plan Report View Drug Benefit Summary

Pharmacy & Mail Order Information

Mail Order is available.
Pharmacy Network [?]
1 network pharmacies in your ZIP code
Preferred pharmacy network available [?]
Pharmacy Network [?]
Drug List

Add/Edit Drugs

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