Page 20 - Rx Drug Plan review for John

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?

Costco
Walgreens #6126 Pharmacy CVS Pharmacy
#05267
Preferred Preferred #746
in-network Out-of- Standard in-

pharmacy network network
pharmacy
pharmacy

Carvedilol 25mg
tablet $58.80 $1,506.12 $120.91

Diltiazem
hydrochloride

240mg capsule $78.30 $578.16 $276.65
extended release 24
hour

Febuxostat 40mg

tablet

$301.91 $4,187.04 $300.07

Hydrochlorothiazide
50mg tablet $22.65 $29.04 $20.97

Metformin

hydrochloride $3.84 $1,017.84 $101.39
1000mg tablet