Page 76 - APPENDICES for Stephen Spero

Mail order pharmacy - Drug costs during coverage phases

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

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

Januvia 100mg tablet $1,363.39 $1,363.39 $141.00 $340.85 $68.17

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

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

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

Monthly totals $3,060.89 $3,035.96 $431.47 $758.99 $162.32

Estimated total drug + premium cost

You will pay $1,536.98 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 November
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
Mail-order costs for the last
Time period Estimated monthly drug costs three months are $836.06 +

$17.40 in premiums =
August $836.06 $853.46.

November $671.92

OTHER DRUG INFORMATION