Page 55 - Appendices for Rick Leininger

Mail order pharmacy - Drug costs during coverage phases

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

Metoprolol tartrate 37.5mg
$170.93 $3.00 $42.73 $8.55
tablet

Pravastatin sodium 10mg
$18.01 $3.00 $4.50 $3.70
tablet

Tamsulosin hydrochloride
$25.06 $9.00 $6.26 $3.70
0.4mg capsule

Xarelto 20mg tablet $1,513.25 $129.00 $378.31 $75.66

Monthly totals $1,727.24 $144.00 $431.80 $91.61

Estimated total drug + premium cost

You will pay $1,254.24 per year on drug + premium costs.

Based on current drug costs, it's estimated that:
You'll enter the coverage gap in December
You won't exit the coverage gap
If you were enrolled
for 7 months this
Estimated monthly drug costs year, you would

enter the coverage
This doesn't include your monthly plan premium of $79.90. gap known as the
donut hole.
View the costs of your drugs every month

Time period Estimated monthly drug costs

June July $144.00 Two quarterly co-payments of $144 ($288
total) plus six monthly premiums of $79.90 =
$767.40 for the last six months of 2021.
September October $144.00

December $406.94
higher costs as you
enter the donut hole

OTHER DRUG INFORMATION