Page 44 - Appendices for Patti's Evaluation
P. 44
Estimated total drug + premium cost
You will pay $68.50 per year on drug + premium costs.
Based on current drug costs, it's estimated that:
You won't meet your $435.00 deductible this year
Estimated monthly drug costs
This doesn't include your monthly plan premium of $13.70.
View the costs of your drugs every month
Time period Estimated monthly drug costs
August $0.00
September $0.00
October $0.00
November $0.00
December $0.00
Costco is a preferred
pharmacy in this
plan, and so you will
get the lowest prices
COSTCO PHARMACY #746 - Drug costs during coverage phases
there.
Preferred in-network pharmacy
Cost in
Retail Cost before Cost after Cost after
Selected drugs coverage
cost deductible deductible coverage gap
gap
Atorvastatin 40mg
$2.81 $0.00 $0.00 $0.70 $2.81
tablet
Levothyroxine sodium
$12.06 $0.00 $0.00 $3.01 $3.60
112mcg tablet
Ramipril 2.5mg capsule $1.32 $0.00 $0.00 $0.33 $1.32
Monthly totals $16.19 $0.00 $0.00 $4.04 $7.73
Estimated total drug + premium cost
