Page 37 - APPENDICES for Janet Tuma
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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.
OSCO DRUG #0052 - Drug costs during coverage phases
Preferred in-network pharmacy
Cost in
Retail Cost after Cost after
Selected drugs coverage
cost deductible coverage gap
gap
Diltiazem hydrochloride 300mg capsule
$3.67 $3.67 $3.67 $3.67
extended release 24 hour
Hydrochlorothiazide 25mg tablet $0.52 $0.00 $0.00 $0.52
Monthly totals $4.18 $3.67 $3.67 $4.19
Estimated total drug + premium cost
You will pay $36.70 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 $0.00.
View the costs of your drugs every month
Time period Estimated monthly drug costs
March $3.67
April $3.67
May $3.67
June $3.67
