Page 56 - APPENDICES for Stephen Spero

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

Atorvastatin 10mg tablet $5.06 $0.00 $0.00 $3.60

Januvia 100mg tablet $477.69 $47.00 $119.42 $23.88

Lisinopril 10mg tablet $2.03 $0.00 $0.00 $2.03

Metformin hcl er (osm) 1000mg tablet
$407.21 $100.00 $101.80 $20.36
extended release 24 hour

Temazepam 15mg capsule $3.17 $3.17 $0.79 $3.17

Monthly totals $895.14 $150.17 $222.01 $53.04

Estimated total drug + premium cost

You will pay $838.11 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You'll enter the coverage gap in December

You won't exit the coverage gap

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

August $150.17
Costs for your Rx
drugs for last 3
September $147.00
months of this year
at Rite Aid are
October $150.17
$447.34.

November $147.00

December $243.77