Page 81 - APPENDICES for Diane Falten
P. 81
YEARLY DRUG COSTS BY PHARMACY
Drug costs shown vary based on the plan and pharmacy that you use. Contact the plan if you have speci c
questions about drug costs. Can my drug costs change by pharmacy?
CVS Pharmacy #10463
Preferred Preferred in-network pharmacy
Amlodipine 5mg tablet $24.00
Atorvastatin 20mg tablet $24.00
Losartan potassium 100mg tablet $24.00
Memantine hydrochloride 5mg
tablet $120.00
Metformin hydrochloride
1000mg tablet $22.20
Omeprazole 40mg capsule
delayed release $24.00
Trazodone hydrochloride 50mg
tablet
These are your total Rx drug co-
$19.68 payments. When you add in your
annual Rx drug premiums of $214.80
(12 months x $17.90 a month), your
total drug costs including premiums =
Total yearly drug cost $257.88 $472.68.
