Page 96 - 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 $16.20 $16.20 $0.00 $4.05 $3.60

Januvia 100mg tablet $1,463.40 $1,463.40 $90.00 $365.85 $73.17

Lisinopril 10mg tablet $25.20 $25.20 $0.00 $6.30 $3.60

Metformin hcl er (osm) 1000mg
$224.10 $224.10 $73.95 $56.03 $11.21
tablet extended release 24 hour

Temazepam 15mg capsule $12.60 $12.60 $6.00 $3.15 $3.60

Monthly totals $1,741.50 $1,741.50 $169.95 $435.38 $95.18

Estimated total drug + premium cost

You will pay $861.45 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 won't enter the coverage gap this year

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
In this plan your mail-order
August $525.00 costs for the last three months
are $525 + $99.90 in
November $169.95 premiums = $624.90.

OTHER DRUG INFORMATION