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HUMANA

Humana Walmart Value Rx Plan (PDP)

Plan type: Drug plan (Part D)
Plan ID: S5884-186-0
Plan website Non-members: 1-800-706-0872 Members: 1-800-281-6918

What you'll pay

Total monthly premium Retail pharmacy: 2022 estimated total drug costs Mail order pharmacy: 2022 estimated total drug costs

$22.70 $843.59 $837.20

Covers 3 of 3 drugs Covers 3 of 3 drugs

Overview

PREMIUMS

Total monthly premium $22.70

DEDUCTIBLES

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible $480.00

CONTACT INFORMATION

Plan address 500 West Main Street

Louisville, KY 40202
Drug Coverage
See if there's help to lower costs for drugs you take.

PHARMACIES

See the cost level to fill your drugs at the pharmacies you chose. You can also change pharmacies to see the cost level of other pharmacies in your area to find
the lowest cost pharmacy.

Preferred Preferred in-network pharmacy

SAFEWAY PHARMACY #0878

Preferred Preferred in-network pharmacy

WALMART PHARMACY 10-2258

Preferred Preferred in-network pharmacy

COSTCO PHARMACY #1115

WALGREENS #19804 Standard in-network pharmacy

Preferred Preferred in-network pharmacy

Mail Order Pharmacy Costs vary based on the specific mail-order pharmacy

YEARLY DRUG COSTS BY PHARMACY

Drug costs shown vary based on the plan and pharmacy that you use. Contact the plan if you have specific questions about drug costs. Can my drug costs change
pharmacy?

Safeway Pharmacy Walmart Pharmacy Costco Pharmacy Walgreens Mail Order

#0878 10-2258 #1115 #19804 Pharmacy
Preferred Preferred Preferred Preferred Preferred Preferred Standard Preferred Prefe
  in- in- in- in- in-
network network network network netw
pharmacy pharmacy pharmacy pharmacy phar

Atorvastatin 10mg
tablet $12.00 $11.40 $12.00 $85.80 $6.60

Estradiol 10mcg
tablet $819.59 $972.82 $820.56 $895.32 $818.60

Hydrochlorothiazide
/ triamterene 37.5- $12.00 $12.00 $12.00 $85.80 $12.00
25mg tablet

Total yearly drug

$843.59 $996.22 $844.56 $1,066.92 $837.20
cost
ESTIMATED TOTAL DRUG + PREMIUM COST

Safeway Pharmacy Walmart Pharmacy Costco Pharmacy Walgreens Mail Order

#0878 10-2258 #1115 #19804 Pharmacy
Preferred Preferred Preferred Preferred Preferred Preferred Standard Preferred Preferred
  in- in- in- in- in-
network network network network network
pharmacy pharmacy pharmacy pharmacy pharmacy

Total yearly
drug +
$1,115.99 $1,268.62 $1,116.96 $1,339.32 $1,109.60
premium
cost

When you'll
meet your May 2022 April 2022 May 2022 May 2022 April 2022
deductible

When You won't

you'll You won't enter the You won't enter the You won't enter the enter the You won't enter the
enter the
coverage coverage gap in 2022 coverage gap in 2022 coverage gap in 2022 coverage gap coverage gap in 2022
gap in 2022
ESTIMATED TOTAL MONTHLY DRUG COST

Safeway Pharmacy Walmart Pharmacy Costco Pharmacy Walgreens Mail Order

#0878 10-2258 #1115 #19804 Pharmacy
Preferred Preferred Preferred Preferred Preferred Preferred Standard Preferred Preferred
  in- in- in- in- in-
network network network network network
pharmacy pharmacy pharmacy pharmacy pharmacy

January $111.02 $142.11 $111.22 $123.52 $331.11

February $111.02 $142.11 $111.22 $123.52 -

March $111.02 $142.11 $111.22 $123.52 -

April $111.02 $94.53 $111.22 $123.52 $229.09

May $72.61 $59.42 $72.22 $90.47 -

June $46.70 $59.42 $46.78 $68.91 -

July $46.70 $59.42 $46.78 $68.91 $138.50

August $46.70 $59.42 $46.78 $68.91 -

September $46.70 $59.42 $46.78 $68.91 -

October $46.70 $59.42 $46.78 $68.91 $138.50

November $46.70 $59.42 $46.78 $68.91 -

December $46.70 $59.42 $46.78 $68.91 -

ESTIMATED DRUG COSTS DURING COVERAGE PHASES

The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if you have specific questions about drug costs.

Learn more about coverage phases.

SAFEWAY PHARMACY #0878

Retail Cost before Cost after Cost in Cost after

 
cost deductible deductible coverage gap coverage gap

Atorvastatin 10mg tablet $1.50 $1.00 $1.00 $0.38 $1.50

Estradiol 10mcg tablet $109.02 $109.02 $44.70 $27.26 $5.45

Hydrochlorothiazide / triamterene
$4.80 $1.00 $1.00 $1.20 $3.95
37.5-25mg tablet

Monthly totals $115.32 $111.02 $46.70 $28.84 $10.90

WALMART PHARMACY 10-2258

Retail Cost before Cost after Cost in Cost after

 
cost deductible deductible coverage gap coverage gap

Atorvastatin 10mg tablet $0.95 $0.95 $0.95 $0.24 $0.95

Estradiol 10mcg tablet $140.16 $140.16 $57.47 $35.04 $7.01

Hydrochlorothiazide / triamterene
$1.70 $1.00 $1.00 $0.43 $1.70
37.5-25mg tablet

Monthly totals $142.81 $142.11 $59.42 $35.71 $9.66

COSTCO PHARMACY #1115

Retail Cost before Cost after Cost in Cost after

 
cost deductible deductible coverage gap coverage gap

Atorvastatin 10mg tablet $1.70 $1.00 $1.00 $0.43 $1.70

Estradiol 10mcg tablet $109.22 $109.22 $44.78 $27.31 $5.46

Hydrochlorothiazide / triamterene
$5.00 $1.00 $1.00 $1.25 $3.95
37.5-25mg tablet

Monthly totals $115.92 $111.22 $46.78 $28.99 $11.11

 WALGREENS #19804

Retail Cost before Cost after Cost in Cost after

 
cost deductible deductible coverage gap coverage gap

Atorvastatin 10mg tablet $7.15 $7.15 $7.15 $1.79 $3.95

Estradiol 10mcg tablet $109.22 $109.22 $54.61 $27.31 $5.46

Hydrochlorothiazide / triamterene
$7.15 $7.15 $7.15 $1.79 $3.95
37.5-25mg tablet

Monthly totals $123.52 $123.52 $68.91 $30.89 $13.36

MAIL ORDER PHARMACY

Retail Cost before Cost after Cost in Cost after

 
cost deductible deductible coverage gap coverage gap

Atorvastatin 10mg tablet $1.65 $1.65 $1.65 $0.41 $1.65

Estradiol 10mcg tablet $326.46 $326.46 $133.85 $81.62 $16.32

Hydrochlorothiazide / triamterene
$3.90 $3.00 $3.00 $0.98 $3.90
37.5-25mg tablet

Monthly totals $332.01 $331.11 $138.50 $83.01 $21.87

COSTS BY DRUG TIER

Plans group their drug lists into tiers. The drug costs below show how much you'll pay for drugs in each tier based on the coverage phase you're in.

Learn more about drug tiers.

 Initial coverage phase Gap coverage phase Catastrophic coverage phase

Generic drugs: Generic drugs:

25% $3.95 copay or 5% (whichever costs more)
Preferred Generic $1.00 copay
Brand-name drugs: Brand-name drugs:
25% $9.85 copay or 5% (whichever costs more)

Generic drugs: Generic drugs:

25% $3.95 copay or 5% (whichever costs more)
Generic $4.00 copay
Brand-name drugs: Brand-name drugs:
25% $9.85 copay or 5% (whichever costs more)

Generic drugs: Generic drugs:

Preferred Brand 18%

25% $3.95 copay or 5% (whichever costs more)

Brand-name drugs: Brand-name drugs:

25% $9.85 copay or 5% (whichever costs more)

Generic drugs: Generic drugs:

25% $3.95 copay or 5% (whichever costs more)
Non-Preferred Drug 41%
Brand-name drugs: Brand-name drugs:
25% $9.85 copay or 5% (whichever costs more)

Generic drugs: Generic drugs:

25% $3.95 copay or 5% (whichever costs more)
Specialty Tier 25%
Brand-name drugs: Brand-name drugs:
25% $9.85 copay or 5% (whichever costs more)

OTHER DRUG INFORMATION

  Tier Prior authorization Quantity limits Step therapy

Atorvastatin 10mg tablet Tier 1 — — —

Estradiol 10mcg tablet Tier 4 — — —

Hydrochlorothiazide / triamterene 37.5-25mg tablet Tier 1 — — —

MY DRUG LIST

  Package Quantity Frequency Brand/Generic

Atorvastatin 10mg tablet 15 Every month Generic

Estradiol 10mcg tablet 8 Every month Generic

Hydrochlorothiazide / triamterene 37.5-25mg tablet 30 Every month Generic

PART B DRUGS
These are drugs you usually get at a doctor's office or hospital outpatient setting, like the flu shot, chemotherapy, or other shots.

Chemotherapy drugs Not covered

Other Part B drugs Not covered

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Overall rating is based on the categories below.

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Summary rating of drug plan quality