Prescription Cost Worksheet
Name or initials (optional): __________________ Date: ______________
Keep quotes comparable
Prescribed product / strength / formulation: __________________________________
Quantity and days of supply: __________________________________
Quote date and contact: __________________________________
Record each option
Insurance quote: $________ Shipping: $________ Days covered: ________
Cash / discount quote: $________ Shipping: $________ Days covered: ________
Mail-order quote: $________ Shipping: $________ Days covered: ________
Other fees or membership costs: __________________________________
Questions before deciding
How does this purchase affect my benefits, deductible, or refill eligibility?
Are the quotes for the same product, quantity, and supply period?
Have I verified the pharmacy and support arrangements?
Which details need confirmation? __________________________________