Page 101 - Appendices for Eric Hartman
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WALGREENS #12140
You may have to pay the full cost for drugs. Choose an in-network pharmacy to get drugs at
a lower cost. Find an in-network pharmacy.
Cost
Cost Cost in
Retail Cost after after
before coverage
cost deductible coverage
deductible gap
gap
Atorvastatin
10mg tablet $118.87 $118.87 $118.87 $118.87 $118.87
Finasteride
5mg tablet $91.92 $91.92 $91.92 $91.92 $91.92
Levothyroxine
sodium 25mcg $14.70 $14.70 $14.70 $14.70 $14.70
tablet
Terazosin 2mg
$91.55 $91.55 $91.55 $91.55 $91.55
capsule
Monthly totals $317.04 $317.04 $317.04 $317.04 $317.04
