Page 70 - APPENDICES for Fred Falten

Pharmacies Change Pharmacies

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

More about pharmacy cost levels

CVS PHARMACY #00846 Preferred in-network pharmacy

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

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 speci c questions about drug costs.

Learn more about coverage phases.

CVS PHARMACY #00846 - Drug costs during coverage phases

Preferred in-network pharmacy

Retail Cost after Cost in Cost after
Selected drugs
cost deductible coverage gap coverage gap

Amlodipine 2.5mg tablet $2.94 $0.00 $0.73 $2.94

Atorvastatin 20mg tablet $23.08 $0.00 $5.77 $3.70

Metoprolol succinate 50mg tablet
$13.34 $0.00 $3.34 $3.70
extended release 24 hour

Tamsulosin hydrochloride 0.4mg
$20.64 $0.00 $5.16 $3.70
capsule

Monthly totals $60.00 $0.00 $15.00 $14.04

Estimated total drug + premium cost

You will pay $0.00 per year on drug + premium costs.