Page 55 - APPENDICES for Janet Tuma
P. 55
Time period Estimated monthly drug costs
July $4.00
August $4.00
September $4.00
October $4.00
November $4.00
December $4.00
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
$98.10 $8.00 $24.53 $4.91
extended release 24 hour
Hydrochlorothiazide 25mg tablet $6.30 $0.00 $1.58 $3.70
Monthly totals $104.40 $8.00 $26.11 $8.61
Estimated total drug + premium cost
You will pay $32.00 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 $8.00
