Page 38 - APPENDICES for Janet Tuma
P. 38
Time period Estimated monthly drug costs
July $3.67
August $3.67
September $3.67
October $3.67
November $3.67
December $3.67
Mail order pharmacy - Drug costs during coverage phases
Cost in
Retail Cost after Cost after
Selected drugs coverage
cost deductible coverage gap
gap
Diltiazem hydrochloride 300mg capsule
$4.20 $4.20 $4.20 $3.70
extended release 24 hour
Hydrochlorothiazide 25mg tablet $0.09 $0.00 $0.00 $0.09
Monthly totals $4.29 $4.20 $4.20 $3.79
Estimated total drug + premium cost
You will pay $16.80 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 $4.20
