Page 88 - APPENDICES for Fred Falten

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 $0.00 $0.00 $0.00 $0.00 $0.00

Atorvastatin 20mg tablet $0.00 $0.00 $0.00 $0.00 $0.00

Metoprolol succinate 50mg tablet
$0.00 $0.00 $0.00 $0.00 $0.00
extended release 24 hour

Tamsulosin hydrochloride 0.4mg
$0.00 $0.00 $0.00 $0.00 $0.00
capsule

Monthly totals $0.00 $0.00 $0.00 $0.00 $0.00

Estimated total drug + premium cost

You will pay $0.00 per year on drug + premium costs.

Based on current drug costs, it's estimated that:
You won't meet your $300.00 deductible 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

April $0.00

July $0.00

October $0.00

OTHER DRUG INFORMATION