Page 49 - APPENDICES for Vic Bosiger

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

Alprazolam

0.5mg tablet $2.40 $2.40 $2.40 $0.60 $2.40

Amlodipine
5mg tablet $3.72 $3.72 $3.72 $0.93 $3.72

Carvedilol
25mg tablet $11.01 $5.00 $5.00 $2.75 $3.95

Farxiga 10mg

tablet $536.46 $47.00 $47.00 $134.11 $26.82

Furosemide
40mg tablet $6.00 $5.00 $5.00 $1.50 $3.95

Glipizide
$10.25 $5.00 $5.00 $2.56 $3.95
10mg tablet

Isosorbide

mononitrate
30mg tablet
extended $12.66 $5.00 $5.00 $3.17 $3.95
release 24
hour

Lisinopril
20mg tablet $14.87 $5.00 $5.00 $3.72 $3.95