Page 84 - 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 $2.87 $2.00 $2.00 $0.72 $2.87

Atorvastatin
20mg tablet $22.70 $2.00 $2.00 $5.68 $3.95

Losartan
potassium $6.19 $2.00 $2.00 $1.55 $3.95
100mg tablet

Memantine
hydrochloride $30.71 $10.00 $10.00 $7.68 $3.95
5mg tablet

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

1000mg tablet

Omeprazole
40mg capsule $7.84 $2.00 $2.00 $1.96 $3.95

delayed release

Trazodone
hydrochloride $1.64 $1.64 $1.64 $0.41 $1.64
50mg tablet

Monthly totals $73.79 $21.49 $21.49 $18.46 $22.16