Page 44 - APPENDICES for Neill McLauchlin

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.

WALMART PHARMACY 10-1666 - Drug costs during coverage
phases

Preferred in-network pharmacy

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

Lisinopril 40mg tablet $12.03 $0.00 $3.01 $3.70

Methimazole 5mg tablet $5.58 $5.58 $1.40 $3.70

Propranolol hydrochloride 120mg capsule
$45.33 $42.00 $11.33 $3.70
extended release 24 hour

Tolterodine tartrate 4mg capsule extended
$237.63 $42.00 $59.41 $11.88
release 24 hour

Monthly totals $300.57 $89.58 $75.15 $22.98

Estimated total drug + premium cost

You will pay $806.22 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't enter the coverage gap 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 $89.58