Page 77 - Appendices for Eric Hartman
P. 77
WALGREENS #12140
Cost in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap
Atorvastatin 10mg
tablet $7.60 $7.60 $7.60 $4.15
Finasteride 5mg tablet $9.85 $0.00 $2.46 $4.15
Levothyroxine sodium
25mcg tablet $11.35 $0.00 $2.84 $4.15
Terazosin 2mg capsule $20.35 $0.00 $5.09 $4.15
Monthly totals $49.15 $7.60 $17.99 $16.60
