Page 76 - 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 in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap

Atorvastatin 10mg
tablet $12.10 $10.00 $10.00 $4.15

Finasteride 5mg tablet $13.00 $0.00 $3.25 $4.15

Levothyroxine sodium
25mcg tablet $10.90 $0.00 $2.73 $4.15

Terazosin 2mg capsule $19.90 $0.00 $4.98 $4.15

Monthly totals $55.90 $10.00 $20.96 $16.60