Page 95 - APPENDICES for Stephen Spero

Cost in
Cost after
Cost Cost in Cost after
Cost
Retail
Cost after
Retail Cost after
before
coverage
coverage
Selected drugs
Selected drugs before coverage coverage
deductible
cost deductible
cost
deductible gap gap
deductible
gap
gap
Atorvastatin 10mg tablet $8.41 $8.41 $1.00 $2.10 $3.60
Januvia 100mg tablet $506.86 $506.86 $30.00 $126.72 $25.34
Lisinopril 10mg tablet $7.51 $7.51 $0.00 $1.88 $3.60
Metformin hcl er (osm) 1000mg
$484.51 $484.51 $159.89 $121.13 $24.23
tablet extended release 24 hour

Temazepam 15mg capsule $8.65 $8.65 $4.00 $2.16 $3.60

Monthly totals $1,015.94 $1,015.94 $194.89 $253.99 $60.37

Estimated total drug + premium cost

You will pay $1,493.23 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 $33.30.

View the costs of your drugs every month

Time period Estimated monthly drug costs

August $489.45
If you get your prescriptions filled at a
September $190.89 Walmart Pharmacy, your costs for the
last 3 months of this year will be
October $194.89 $975.13, including cost-sharing and
premiums.
November $197.51

December $253.99