Plan name___________________________________________ | |||||
Monthly Premium | Yearly Deductible | My Drugs that are Covered | Amount I'd pay for each drug | Could I use my Pharmacy? | Is mail order available? |
$_____ |
$______ |
1___________________ 2___________________ 3___________________ |
1_$_______ 2_$_______ 3_$_______ |
||
Plan name___________________________________________ | |||||
Monthly Premium | Yearly Deductible | My Drugs that are Covered | Amount I'd pay for each drug | Could I use my Pharmacy? | Is mail order available? |
$_____ |
$______ |
1___________________ 2___________________ 3___________________ |
1_$_______ 2_$_______ 3_$_______ |
||
Plan name___________________________________________ | |||||
Monthly Premium | Yearly Deductible | My Drugs that are Covered | Amount I'd pay for each drug | Could I use my Pharmacy? | Is mail order available? |
$_____ |
$______ |
1___________________ 2___________________ 3___________________ |
1_$_______ 2_$_______ 3_$_______ |
||