Page 54 - Appendices for Rick Leininger

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Retail l C o s t a f t e r Cost in Cost after
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S e l e c t e d d r u g s
Selected drugs
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cost deductible coverage gap coverage gap
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Metoprolol tartrate 37.5mg
$66.14 $1.00 $16.54 $3.70
tablet
Pravastatin sodium 10mg
$6.75 $1.00 $1.69 $3.70
tablet
Tamsulosin hydrochloride
$9.24 $3.00 $2.31 $3.70
0.4mg capsule
Xarelto 20mg tablet $504.23 $43.00 $126.06 $25.21
Monthly totals $586.35 $48.00 $146.60 $36.31
Estimated total drug + premium cost
You will pay $895.30 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't enter the coverage gap this year
Estimated monthly drug costs
This doesn't include your monthly plan premium of $79.90.
View the costs of your drugs every month
Time period Estimated monthly drug costs
June $48.00 Costs at a CVS
Pharmacy
July $48.00 $48 in co-pays each month +
$79.90 monthly premium =
August $48.00 $127.90 a month times six months
is $767.40 for the last six months
September $48.00 of this year. If you get 90-day
refills at CVS, your costs for the
last 6 months of this year will
October $48.00
likely be less because of lower
dispensing fees.
November $48.00
December $48.00