Page 94 - Evaluation for Tom Tappan
P. 94
BofA Silverscript Rx Drug Plan estimated annual costs
Monthly Refills
Rx drug and dosage Assumed Tier Monthly Cost
Non-Preferred Brand and
Axiron SOL 30MG/ACT $30
Specialty Drugs
Non-Preferred Brand and
Descovy TAB 200/25 $30
Specialty Drugs
Levothyroxine Sodium TAB 50MCG Generic $5
Non-Preferred Brand and
Nevirapine TAB 400MG ER $30
Specialty Drugs
Zenpep CAP 25000UNT Generic $5
Total estimated monthly cost $100
x 12 months = $1,000
Mail-Order Refills
Quarterly
Rx drug and dosage Assumed Tier
Cost
Non-Preferred Brand and
Axiron SOL 30MG/ACT $60
Specialty Drugs
Non-Preferred Brand and
Descovy TAB 200/25 $60
Specialty Drugs
Levothyroxine Sodium TAB 50MCG Generic $10
Non-Preferred Brand and
Nevirapine TAB 400MG ER $60
Specialty Drugs
Zenpep CAP 25000UNT Generic $10
Total estimated quarterly cost $200
x 4 quarters= $800
