Page 73 - APPENDICES for Stephen Spero

Brand-name drugs:
Initial coverage Gap coverage $8.95 copay or 5% (whichever costs
Tiers Catastrophic coverage phase
phase phase 1 more)

Generic $9.00 copay

Preferred Brand $47.00 copay

Non-Preferred
$95.00 copay
Drug

Specialty Tier 25%

1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

ESTIMATED DRUG COSTS DURING COVERAGE PHASES

The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if
you have speci c questions about drug costs.

Learn more about coverage phases.

RITE AID PHARMACY 05646 - Drug costs during coverage

phases
Standard in-network pharmacy

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

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

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

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

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

Monthly totals $895.14 $888.07 $150.17 $222.01 $53.04