Page 55 - Appendices for Eric Hartman
P. 55

MAIL ORDER PHARMACY





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




       Atorvastatin 10mg
       tablet                            $16.86          $0.00                 $0.00                 $4.15





       Finasteride 5mg tablet            $34.86          $0.00                 $0.00                 $4.15





       Levothyroxine sodium
       25mcg tablet                      $162.66         $0.00                 $0.00                 $8.13




       Terazosin 2mg capsule             $49.26          $0.00                 $0.00                 $4.15





       Monthly totals                    $263.64         $0.00                 $0.00                 $20.58






   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.
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