Page 102 - APPENDICES for Fred Falten
P. 102
Preferred in-network pharmacy
Cost in Cost after
Retail Cost before Cost after
Selected drugs coverage coverage
cost deductible deductible
gap gap
Amlodipine 2.5mg tablet $1.12 $0.00 $0.00 $0.00 $1.12
Atorvastatin 20mg tablet $4.71 $0.00 $0.00 $0.00 $3.70
Metoprolol succinate 50mg tablet
$7.72 $2.00 $2.00 $2.00 $3.70
extended release 24 hour
Tamsulosin hydrochloride 0.4mg
$6.83 $2.00 $2.00 $2.00 $3.70
capsule
Monthly totals $20.37 $4.00 $4.00 $4.00 $12.22
Estimated total drug + premium cost
You will pay $212.40 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't meet your $350.00 deductible this year
Estimated monthly drug costs
This doesn't include your monthly plan premium of $19.60.
View the costs of your drugs every month
Time period Estimated monthly drug costs
April $4.00
May $4.00
June $4.00
July $4.00
August $4.00
September $4.00
October $4.00
