Page 103 - Appendices to Heidi Bathon's Evaluation
P. 103
WALMART PHARMACY 10-3720
Cost in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap
Alprazolam 0.25mg tablet [ 1 ] $20.02 $20.02 $20.02 $20.02
Creon 6000-19000unit capsule delayed
release particles $170.74 $45.00 $42.68 $9.85
Diclofenac epolamine 1.3% patch $755.30 $302.12 $188.83 $37.77
Duloxetine 60mg capsule delayed
release particles $14.21 $10.00 $3.55 $3.95
Estradiol 0.1mg/gm cream $72.30 $45.00 $18.07 $3.95
Levothyroxine sodium 50mcg tablet $3.24 $3.24 $0.81 $3.24
Mirtazapine 45mg tablet $11.62 $10.00 $2.91 $3.95
Omeprazole 20mg capsule delayed
release $8.85 $8.85 $2.21 $3.95
Rosuvastatin calcium 5mg tablet $11.25 $10.00 $2.81 $3.95
Triamcinolone acetonide 0.1% cream $2.33 $2.33 $0.58 $2.33
Monthly totals $1,069.85 $456.56 $282.47 $92.96
[1]
This plan does not cover this drug at the selected frequency, so the price shown represents the full cash price.
