Page 94 - APPENDICES for Stephen Spero

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

Metformin hcl er (osm) 1000mg
$352.25 $352.25 $119.77 $88.06 $17.61
tablet extended release 24 hour

Temazepam 15mg capsule $4.45 $4.45 $4.45 $1.11 $3.60

Monthly totals $857.55 $857.55 $163.52 $214.39 $52.84

Estimated total drug + premium cost

You will pay $1,343.39 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 $33.30.

View the costs of your drugs every month

Time period Estimated monthly drug costs
If you get your Rx
August $467.00 filled at a Rite Aid
pharmacy, your cost
September $159.07 for the last three
months of this year
October $163.52 will be $889.49,
including premiums.
November $159.07

December $228.23

WALMART PHARMACY 10-2479 - Drug costs during coverage

phases

Preferred in-network pharmacy