Page 87 - APPENDICES for Fred Falten
P. 87
Cost in Cost after
Retail Cost before Cost after
Selected drugs coverage coverage
cost deductible deductible
gap gap
Atorvastatin 20mg tablet $4.10 $2.00 $2.00 $1.03 $3.70
Metoprolol succinate 50mg tablet
$6.80 $2.00 $2.00 $1.70 $3.70
extended release 24 hour
Tamsulosin hydrochloride 0.4mg
$6.50 $6.50 $6.50 $1.63 $3.70
capsule
Monthly totals $18.23 $11.33 $11.33 $4.57 $11.93
Estimated total drug + premium cost
You will pay $101.97 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't meet your $300.00 deductible 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 $11.33
May $11.33
June $11.33
July $11.33
August $11.33
September $11.33
October $11.33
November $11.33
December $11.33
