Page 22 - APPENDICES for Vic Bosiger
P. 22
YEARLY DRUG COSTS BY PHARMACY
Drug costs shown vary based on the plan and pharmacy that you use. Contact the plan if you have speci c
questions about drug costs. Can my drug costs change by pharmacy?
CVS Pharmacy #07948
Standard in-network pharmacy
Alprazolam 0.5mg tablet $8.85
Amlodipine 5mg tablet $11.95
Carvedilol 25mg tablet $19.75
Farxiga 10mg tablet $853.58
Furosemide 40mg tablet $17.70
Glipizide 10mg tablet $19.75
Isosorbide mononitrate 30mg
tablet extended release 24 hour $64.17
Lisinopril 20mg tablet $19.75
Metformin hydrochloride
1000mg tablet $15.75
Nitroglycerin 0.4mg tablet
sublingual $78.43
