Explanation of Monthly Drug Costs
1 This number includes the amount you pay for drug copays and drug plan premiums, but not any health coverage premiums your plan may charge.
| Month |
Your Cost1
| ||||
|---|---|---|---|---|---|
| January | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Deductible / Initial Cost | $274.77 | $165.38 | |
| levothyroxine sodium TAB 200MCG | Yes | Deductible | $7.59 | $7.59 | |
| levothyroxine sodium TAB 25MCG | Yes | Deductible | $5.01 | $5.01 | |
| Nexium CAP 40MG | Yes | Deductible | $229.54 | $229.54 | |
| What you’ll spend in January: | $448.52 | ||||
| February | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Initial Cost | $274.77 | $118.15 | |
| levothyroxine sodium TAB 200MCG | Yes | Initial Cost | $7.59 | $2.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Initial Cost | $5.01 | $2.00 | |
| Nexium CAP 40MG | Yes | Initial Cost | $229.54 | $50.50 | |
| What you’ll spend in February: | $213.65 | ||||
| March | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Initial Cost | $274.77 | $118.15 | |
| levothyroxine sodium TAB 200MCG | Yes | Initial Cost | $7.59 | $2.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Initial Cost | $5.01 | $2.00 | |
| Nexium CAP 40MG | Yes | Initial Cost | $229.54 | $50.50 | |
| What you’ll spend in March: | $213.65 | ||||
| April | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Initial Cost | $274.77 | $118.15 | |
| levothyroxine sodium TAB 200MCG | Yes | Initial Cost | $7.59 | $2.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Initial Cost | $5.01 | $2.00 | |
| Nexium CAP 40MG | Yes | Initial Cost | $229.54 | $50.50 | |
| What you’ll spend in April: | $213.65 | ||||
| May | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Initial Cost | $274.77 | $118.15 | |
| levothyroxine sodium TAB 200MCG | Yes | Initial Cost | $7.59 | $2.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Initial Cost | $5.01 | $2.00 | |
| Nexium CAP 40MG | Yes | Initial Cost | $229.54 | $50.50 | |
| What you’ll spend in May: | $213.65 | ||||
| June | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Initial Cost / Gap | $274.77 | $124.06 | |
| levothyroxine sodium TAB 200MCG | Yes | Initial Cost | $7.59 | $2.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Initial Cost | $5.01 | $2.00 | |
| Nexium CAP 40MG | Yes | Initial Cost | $229.54 | $50.50 | |
| What you’ll spend in June: | $219.56 | ||||
| July | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in July: | $290.51 | ||||
| August | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in August: | $290.51 | ||||
| September | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in September: | $290.51 | ||||
| October | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in October: | $290.51 | ||||
| November | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in November: | $290.51 | ||||
| December | Monthly Fee | You Pay | |||
| Drug Premium | $41.00 | ||||
| Drug | Covered Drug | Phase | Full Cost | You Pay | |
| Advair Diskus AER 250/50 | Yes | Gap | $274.77 | $130.52 | |
| levothyroxine sodium TAB 200MCG | Yes | Gap | $7.59 | $6.00 | |
| levothyroxine sodium TAB 25MCG | Yes | Gap | $5.01 | $3.96 | |
| Nexium CAP 40MG | Yes | Gap | $229.54 | $109.03 | |
| What you’ll spend in December: | $290.51 | ||||
| Total Estimated Annual Cost for 2013: | $6,202.92 | ||||
1 This number includes the amount you pay for drug copays and drug plan premiums, but not any health coverage premiums your plan may charge.
Your overall annual out-of-pocket cost is based on:
- Your premium: What you pay each month to your plan for coverage.
- The amount of your plan's annual deductible (the full cost you pay for your drugs before coverage kicks in) if your plan has one.
- What you pay toward the cost of your drugs in the initial coverage period. You pay either a copayment (a fixed-dollar amount) or coinsurance (a percentage of the drug's full cost) for each prescription. Your plan pays the rest.
- Any payments you make for your drugs during the coverage gap (or "doughnut hole"), when you pay the full price that your plan has negotiated with the manufacturers.
- What you pay (no more than 5 percent of the drug's price) during the catastrophic coverage period (if your costs are high enough to reach the out-of-pocket limit that gets you out of the gap before the end of the year)
Except for your premiums, all the above expenses count toward your out-of-pocket limit for the year. On January 1 of each year, you start counting expenses again.
Your Drug List
| Advair Diskus AER 250/50 1 AEPB per month Tier: 2
Quantity Limits
About this drug | Any options to save money? |
| levothyroxine sodium TAB 200MCG 30 TABS per month Tier: 1 About this drug | Any options to save money? |
| levothyroxine sodium TAB 25MCG 30 TABS per month Tier: 1 About this drug | Any options to save money? |
| Nexium CAP 40MG 30 CPDR per month Tier: 2
Quantity Limits
About this drug | Any options to save money? |
Your Pharmacy
These prices are approximate. They reflect the average of what you'd pay at any of your plan's in-network retail pharmacies. Actual costs vary slightly among these pharmacies. Mail-order costs, which are sometimes lower, are not shown. To select a specific pharmacy within your zip code, click here. The pharmacies you find may or may not be in-network. Please contact your plan directly to find out which pharmacies are in-network, including a mail-order pharmacy option.
