Page 57 - APPENDICES for Stephen Spero

WALMART PHARMACY 10-2479 - Drug costs during coverage
phases

Preferred in-network pharmacy

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

Atorvastatin 10mg tablet $6.22 $0.00 $0.00 $3.60

Januvia 100mg tablet $466.23 $42.00 $116.56 $23.31

Lisinopril 10mg tablet $2.35 $0.00 $0.00 $2.35

Metformin hcl er (osm) 1000mg tablet
$519.86 $95.00 $129.96 $25.99
extended release 24 hour

Temazepam 15mg capsule $3.81 $3.81 $0.95 $3.60

Monthly totals $998.46 $140.81 $247.47 $58.85

Estimated total drug + premium cost

You will pay $821.97 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
$418.62 for October-
December if you get
August $140.81
your prescriptions
filled at a Walmart
September $137.00
pharmacy.

October $140.81

November $137.00

December $266.35