Page 43 - Appendices for Patti's Evaluation

Gap coverageap coverage
I Initial coveragenitial coverage G
C
Tiersiers
T Catastrophic coverage phaseatastrophic coverage phase
phasehase
phasehase
p p
Preferred Generic $0.00 copay
Generic drugs:
Generic $5.00 copay Generic drugs: $3.60 copay or 5% (whichever costs
25%
Preferred Brand $40.00 copay more)
Brand-name
Non-Preferred drugs: Brand-name drugs:
46% $8.95 copay or 5% (whichever costs
Drug 25%
more)
Specialty Tier 25%

ESTIMATED DRUG COSTS DURING COVERAGE PHASES

The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if
you have speci c questions about drug costs.

Learn more about coverage phases.

WALMART PHARMACY 10-2077 - Drug costs during coverage

phases

Preferred in-network pharmacy

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

Atorvastatin 40mg
$8.21 $0.00 $0.00 $2.05 $3.60
tablet

Levothyroxine sodium
$12.06 $0.00 $0.00 $3.01 $3.60
112mcg tablet

Ramipril 2.5mg capsule $6.48 $0.00 $0.00 $1.62 $3.60

Monthly totals $26.75 $0.00 $0.00 $6.68 $10.80