Page 72 - APPENDICES for Fred Falten
P. 72
Estimated total drug + premium cost
You will pay $110.10 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't enter the coverage gap this year
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 $36.70
July $36.70
October $36.70
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Amlodipine 2.5mg tablet
1
Tier
Atorvastatin 20mg tablet Yes
1
Metoprolol succinate 50mg tablet extended Tier
release 24 hour 1
Tier
Tamsulosin hydrochloride 0.4mg capsule
1
