Page 61 - APPENDICES for Neill McLauchlin
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WALMART PHARMACY 10-1666 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.
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
