Page 53 - Appendices for Eric Hartman
P. 53
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 in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap
Atorvastatin 10mg
tablet $12.55 $0.00 $0.00 $4.15
Finasteride 5mg tablet $13.75 $0.00 $0.00 $4.15
Levothyroxine sodium
25mcg tablet $57.55 $0.00 $0.00 $4.15
Terazosin 2mg capsule $17.95 $0.00 $0.00 $4.15
Monthly totals $101.80 $0.00 $0.00 $16.60
