Coverage Period
First Coverage Month
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January
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Total Coverage Months
0 months
Medication Information
Prescription Name
Retail Cost ($)
Refill Frequency
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Every month
Every 2 months
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Every 6 months
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Number of Refills
0
Total
$0.00
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Please complete the following:
Calculate Original PDP/MA-PD Cost
Cost Breakdown
Total Coverage Period Cost:
$0.00