Page 71 - APPENDICES for Janet Tuma
P. 71
Time period Estimated monthly drug costs
September $5.00
October $5.00
November $5.00
December $5.00
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
$0.00 $0.00 $0.00 $0.00
extended release 24 hour
Hydrochlorothiazide 25mg tablet $0.00 $0.00 $0.00 $0.00
Monthly totals $0.00 $0.00 $0.00 $0.00
Estimated total drug + premium cost
You will pay $0.00 per year on drug + premium costs.
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 $0.00
June $0.00
September $0.00
December $0.00
