Page 49 - Appendices for Steven Decker
P. 49
!"'()'((0*34658*NOUVKWMV
XYWPVP!Z
)[)*/\5]
^!1!4"`
a
bcba
cba
0/!)Z_
2(/*5
.(e!/*
^e!
f+,g!.*h14-i!4/!*5.5
.5(/5)#$+#$+#$+&,,#,$+
#$%&*##%#+"%&,,-(./##%#+/*12*%&,,/52*##%#+7*12*%&,,4*12*##%#+9:;<:=>
?@:=<:AB
CDEFGHI
E
JKLM
NOPQP
RLKSTM
da
cd#$+#$+&,##$$++
5)/^"
/5/!.$#$
#,j)!./*Z*
%1-/!2*/&&,,$##
Co-payments for the first six
months (July through
December in your case) =
$752.57. After adding $145.20
for the six months of Rx drug
premiums, your total
estimated costs at CVS are
$897.77 for July through the
end of the year.

