Page 72 - APPENDICES for Vic Bosiger

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

Alprazolam 0.5mg tablet $1.83 $1.83 $0.46 $1.83

Amlodipine 5mg tablet $2.30 $2.30 $0.58 $2.30

Carvedilol 25mg tablet $3.13 $3.13 $0.78 $3.13

Farxiga 10mg tablet $591.95 $100.00 $147.99 $29.60

Furosemide 40mg tablet $1.54 $1.54 $0.39 $1.54

Glipizide 10mg tablet $4.10 $4.00 $1.03 $3.95

Isosorbide mononitrate 30mg
tablet extended release 24 $7.10 $4.00 $1.78 $3.95
hour

Lisinopril 20mg tablet $5.73 $4.00 $1.43 $3.95

Metformin hydrochloride
1000mg tablet $3.20 $3.20 $0.80 $3.20

Nitroglycerin 0.4mg tablet
sublingual $30.00 $30.00 $7.50 $3.95

Omeprazole 20mg capsule
delayed release $2.12 $2.12 $0.53 $2.12