Page 63 - APPENDICES for Neill McLauchlin
P. 63
You will pay $664.20 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 $221.40
July $221.40
October $221.40
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Lisinopril 40mg tablet
1
Tier
Methimazole 5mg tablet
2
Propranolol hydrochloride 120mg capsule Tier
extended release 24 hour 3
Tolterodine tartrate 4mg capsule extended Tier
release 24 hour 3
