Page 64 - APPENDICES for Diane Falten

CVS PHARMACY #10463

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

Amlodipine 5mg

tablet $2.00 $2.00 $2.00 $0.50 $2.00

Atorvastatin
20mg tablet $4.40 $2.00 $2.00 $1.10 $3.95

Losartan
potassium $2.90 $2.00 $2.00 $0.73 $2.90
100mg tablet

Memantine
hydrochloride $7.25 $7.25 $7.25 $1.81 $3.95
5mg tablet

Metformin
hydrochloride $1.85 $1.85 $1.85 $0.46 $1.85

1000mg tablet

Omeprazole
40mg capsule $2.90 $2.00 $2.00 $0.73 $2.90

delayed release

Trazodone
hydrochloride $1.70 $1.70 $1.70 $0.43 $1.70
50mg tablet

Monthly totals $23.00 $18.80 $18.80 $5.76 $19.25