Page 102 - Appendices to Heidi Bathon's Evaluation
P. 102
CVS PHARMACY #05381
See footnote
Cost in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap
Alprazolam 0.25mg tablet [ 1 ] $20.42 $20.42 $20.42 $20.42
Creon 6000-19000unit capsule delayed
release particles $171.61 $47.00 $42.90 $9.85
Diclofenac epolamine 1.3% patch $757.83 $341.03 $189.46 $37.89
Duloxetine 60mg capsule delayed
release particles $17.48 $17.48 $4.37 $3.95
Estradiol 0.1mg/gm cream $82.26 $47.00 $20.57 $4.11
Levothyroxine sodium 50mcg tablet $9.87 $9.87 $2.47 $3.95
Mirtazapine 45mg tablet $20.80 $20.00 $5.20 $3.95
Omeprazole 20mg capsule delayed
release $7.01 $7.01 $1.75 $3.95
Rosuvastatin calcium 5mg tablet $11.63 $11.63 $2.91 $3.95
Triamcinolone acetonide 0.1% cream $7.19 $7.19 $1.80 $3.95
Monthly totals $1,106.10 $528.63 $291.85 $95.97
[1]
This plan does not cover this drug at the selected frequency, so the price shown represents the full cash price.
