Page 103 - APPENDICES for Fred Falten

Time period Estimated monthly drug costs

November $4.00

December $4.00

Mail order pharmacy - Drug costs during coverage phases

Cost in Cost after
Retail Cost before Cost after
Selected drugs coverage coverage
cost deductible deductible
gap gap

Amlodipine 2.5mg tablet $2.15 $0.00 $0.00 $0.00 $2.15

Atorvastatin 20mg tablet $12.94 $0.00 $0.00 $0.00 $3.70

Metoprolol succinate 50mg tablet
$21.95 $6.00 $6.00 $6.00 $3.70
extended release 24 hour

Tamsulosin hydrochloride 0.4mg
$19.28 $6.00 $6.00 $6.00 $3.70
capsule

Monthly totals $56.32 $12.00 $12.00 $12.00 $13.25

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 $12.00

July $12.00