Page 71 - APPENDICES for Fred Falten
P. 71
Estimated monthly drug costs
This doesn't include your monthly plan premium of $0.00.
View the costs of your drugs every month
Time period Estimated monthly drug costs
April $0.00
May $0.00
June $0.00
July $0.00
August $0.00
September $0.00
October $0.00
November $0.00
December $0.00
Mail order pharmacy - Drug costs during coverage phases
Cost in
Retail Cost after Cost after
Selected drugs coverage
cost deductible coverage gap
gap
Amlodipine 2.5mg tablet $6.70 $6.70 $1.67 $3.70
Atorvastatin 20mg tablet $62.09 $10.00 $15.52 $3.70
Metoprolol succinate 50mg tablet
$35.32 $10.00 $8.83 $3.70
extended release 24 hour
Tamsulosin hydrochloride 0.4mg
$55.39 $10.00 $13.85 $3.70
capsule
Monthly totals $159.49 $36.70 $39.87 $14.80
