Page 42 - APPENDICES for Diane Falten
P. 42
The drug prices shown may vary based on the plan and pharmacy you've selected. Contact the plan if you have
speci c questions about drug costs.
Learn more about coverage phases.
CVS PHARMACY #10463
Cost in Cost after
Retail Cost after
coverage coverage
cost deductible
gap gap
Amlodipine 5mg tablet $2.87 $0.00 $0.72 $2.87
Atorvastatin 20mg tablet $22.70 $0.00 $5.68 $3.95
Losartan potassium
100mg tablet $6.19 $0.00 $1.55 $3.95
Memantine hydrochloride
5mg tablet $30.71 $10.00 $7.68 $3.95
Metformin hydrochloride
1000mg tablet $1.85 $0.00 $0.46 $1.85
Omeprazole 40mg
capsule delayed release $7.84 $0.00 $1.96 $3.95
Trazodone hydrochloride
50mg tablet $1.64 $0.00 $0.41 $1.64
Monthly totals $73.79 $10.00 $18.46 $22.16
COSTS BY DRUG TIER
