Page 102 - Appendices for Eric Hartman

MAIL ORDER PHARMACY

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

Atorvastatin
10mg tablet $2.79 $2.79 $2.79 $0.70 $2.79

Finasteride 5mg
tablet $5.62 $5.62 $5.62 $1.40 $4.15

Levothyroxine
sodium 25mcg $5.60 $5.60 $5.60 $1.40 $4.15
tablet

Terazosin 2mg
capsule $11.20 $6.00 $6.00 $2.80 $4.15

Monthly totals $25.20 $20.01 $20.01 $6.30 $15.24

COSTS BY DRUG TIER

Plans group their drug lists into tiers. The drug costs below show how much you'll pay for drugs in each tier
based on the coverage phase you're in.

Learn more about drug tiers.