Page 104 - Appendices to Heidi Bathon's Evaluation
P. 104
WALGREENS #19577
Cost in
Retail Cost after Cost after
coverage
cost deductible coverage gap
gap
Alprazolam 0.25mg tablet [ 1 ] $20.17 $20.17 $20.17 $20.17
Creon 6000-19000unit capsule delayed
release particles $170.89 $45.00 $42.72 $9.85
Diclofenac epolamine 1.3% patch $755.45 $302.18 $188.86 $37.77
Duloxetine 60mg capsule delayed
release particles $8.67 $8.67 $2.17 $3.95
Estradiol 0.1mg/gm cream $117.30 $45.00 $29.33 $5.87
Levothyroxine sodium 50mcg tablet $5.29 $5.00 $1.32 $3.95
Mirtazapine 45mg tablet $10.11 $10.00 $2.53 $3.95
Omeprazole 20mg capsule delayed
release $8.73 $8.73 $2.18 $3.95
Rosuvastatin calcium 5mg tablet $10.99 $10.00 $2.75 $3.95
Triamcinolone acetonide 0.1% cream $4.56 $4.56 $1.14 $3.95
Monthly totals $1,112.15 $459.31 $293.17 $97.36
[1]
This plan does not cover this drug at the selected frequency, so the price shown represents the full cash price.
