Page 58 - APPENDICES for Stephen Spero

Mail order pharmacy - Drug costs during coverage phases

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

Atorvastatin 10mg tablet $18.68 $0.00 $0.00 $3.60

Januvia 100mg tablet $1,363.39 $126.00 $340.85 $68.17

Lisinopril 10mg tablet $6.26 $0.00 $0.00 $3.60

Metformin hcl er (osm) 1000mg tablet
$1,667.10 $285.00 $416.77 $83.35
extended release 24 hour

Temazepam 15mg capsule $5.47 $5.47 $1.37 $3.60

Monthly totals $3,060.89 $416.47 $758.99 $162.32

Estimated total drug + premium cost

You will pay $1,073.39 per year on drug + premium costs.
Based on current drug costs, it's estimated that:

You'll enter the coverage gap in November
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
If you switch to mail-
August $416.47 order, your costs for
3 months are

November $656.92 $416.47 (October -
December)