Page 75 - APPENDICES for Stephen Spero

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

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

Januvia 100mg tablet $466.23 $466.23 $47.00 $116.56 $23.31

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

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

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

Monthly totals $998.46 $989.90 $145.81 $247.47 $58.85

Estimated total drug + premium cost

You will pay $1,290.20 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You'll meet your $435.00 deductible in August

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 $5.80.

View the costs of your drugs every month

Time period Estimated monthly drug costs

August $565.04
If you get monthly refills at a
September $142.00 Walmart pharmacy, your
estimated costs for the last three
October $145.81 months of this year are $870.25
including cost sharing and
November $142.00
premiums.

December $266.35