Page 70 - APPENDICES for Janet Tuma
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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
$23.00 $5.00 $5.75 $3.70
extended release 24 hour
Hydrochlorothiazide 25mg tablet $1.03 $0.00 $0.26 $1.03
Monthly totals $24.03 $5.00 $6.01 $4.73
Estimated total drug + premium cost
You will pay $50.00 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 $5.00
April $5.00
May $5.00
June $5.00
July $5.00
August $5.00
