Page 105 - Appendices to Heidi Bathon's Evaluation

MAIL ORDER PHARMACY

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

Alprazolam 0.25mg tablet $13.27 $0.00 $3.32 $3.95

Creon 6000-19000unit capsule delayed
release particles $510.86 $120.00 $127.71 $25.54

Diclofenac epolamine 1.3% patch $2,264.56 $905.82 $566.14 $113.23

Duloxetine 60mg capsule delayed
release particles $38.30 $0.00 $9.57 $3.95

Estradiol 0.1mg/gm cream $356.95 $120.00 $89.24 $17.85

Levothyroxine sodium 50mcg tablet $30.20 $0.00 $7.55 $3.95

Mirtazapine 45mg tablet $44.97 $0.00 $11.24 $3.95

Omeprazole 20mg capsule delayed
release $38.11 $0.00 $9.53 $3.95

Rosuvastatin calcium 5mg tablet $47.80 $0.00 $11.95 $3.95

Triamcinolone acetonide 0.1% cream $19.03 $0.00 $4.76 $3.95

Monthly totals $3,364.05 $1,145.82 $841.01 $184.27

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.