Page 100 - Appendices for Eric Hartman

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 #09373

Cost
Cost Cost in
Retail Cost after after
before coverage
cost deductible coverage
deductible gap
gap

Atorvastatin
10mg tablet $2.26 $2.26 $2.26 $0.57 $2.26

Finasteride 5mg
tablet $2.27 $2.00 $2.00 $0.57 $2.27

Levothyroxine

sodium 25mcg $2.27 $2.00 $2.00 $0.57 $2.27
tablet

Terazosin 2mg

capsule $4.13 $2.00 $2.00 $1.03 $4.13

Monthly totals $10.93 $8.26 $8.26 $2.74 $10.93