Page 45 - Appendices for Patti's Evaluation
P. 45
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
This year your only costs
September $0.00 for the 3 drugs listed on
the first page of this
October $0.00 appendix are your $13.70
a month premiums (4
November $0.00
months x $13.70 = $54.80
December $0.00
CVS PHARMACY #05267 - Drug costs during coverage phases
Standard in-network pharmacy
Cost in
Retail Cost before Cost after Cost after
Selected drugs coverage
cost deductible deductible coverage gap
gap
Atorvastatin 40mg
$16.65 $8.00 $8.00 $4.16 $3.60
tablet
Levothyroxine sodium
$12.16 $8.00 $8.00 $3.04 $3.60
112mcg tablet
Ramipril 2.5mg capsule $10.09 $8.00 $8.00 $2.52 $3.60
Monthly totals $38.90 $24.00 $24.00 $9.72 $10.80
Estimated total drug + premium cost
You will pay $188.50 per year on drug + premium costs.
