Page 46 - Appendices for Patti's Evaluation
P. 46
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 $24.00
September $24.00
October $24.00
November $24.00
December $24.00
OTHER DRUG INFORMATION
Selected drugs Tier Prior Quantity Step
authorization limits therapy
Tier
Atorvastatin 40mg tablet
1
Levothyroxine sodium 112mcg Tier
tablet 1
Tier
Ramipril 2.5mg capsule
1
