Page 86 - APPENDICES for Fred Falten

Initial coverage Gap coverage
Tiers Catastrophic coverage phase
phase phase

Specialty Tier 27%

Pharmacies Change Pharmacies

See the cost level to ll your drugs at the pharmacies you chose. You can also change pharmacies to see
the cost level of other pharmacies in your area to nd the lowest cost pharmacy.

More about pharmacy cost levels

CVS PHARMACY #00846 Preferred in-network pharmacy

Mail Order Pharmacy Costs vary based on the speci c mail-order pharmacy

ESTIMATED DRUG COSTS DURING COVERAGE PHASES

The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if
you have speci c questions about drug costs.

Learn more about coverage phases.

CVS PHARMACY #00846 - Drug costs during coverage phases

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 $0.83 $0.83 $0.83 $0.21 $0.83

Monthly totals $18.23 $11.33 $11.33 $4.57 $11.93