Page 25 - APPENDICES for Vic Bosiger

Cost
Cost in
Retail Cost after after
coverage
cost deductible coverage
gap
gap

Alprazolam 0.5mg tablet $1.77 $0.00 $0.00 $1.77

Amlodipine 5mg tablet $2.39 $0.00 $0.00 $2.39

Carvedilol 25mg tablet $6.29 $0.00 $0.00 $3.95

Farxiga 10mg tablet $570.08 $47.00 $142.52 $28.50

Furosemide 40mg tablet $3.54 $0.00 $0.00 $3.54

Glipizide 10mg tablet $4.16 $0.00 $0.00 $3.95

Isosorbide mononitrate 30mg
tablet extended release 24 $11.10 $11.10 $2.78 $3.95
hour

Lisinopril 20mg tablet $4.34 $0.00 $0.00 $3.95

Metformin hydrochloride
1000mg tablet $3.15 $0.00 $0.00 $3.15

Nitroglycerin 0.4mg tablet
sublingual $16.66 $14.00 $4.17 $3.95

Omeprazole 20mg capsule
delayed release $8.34 $8.34 $2.08 $3.95