Page 26 - Rx Drug Plan review for John

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

Carvedilol 25mg

tablet $7.84 $7.84 $7.84 $1.96 $3.95

Diltiazem
hydrochloride
240mg capsule $10.44 $10.44 $10.44 $2.61 $3.95
extended release 24

hour

Febuxostat 40mg
tablet $40.77 $40.77 $40.00 $10.19 $3.95

Hydrochlorothiazide
50mg tablet [ 2 ] $6.04 $6.04 $6.04 $6.04 $6.04

Metformin

hydrochloride $2.57 $0.00 $0.00 $0.64 $2.57
1000mg tablet

Multaq 400mg
tablet $731.26 $731.26 $40.00 $182.82 $36.56

[1]
This plan does not cover this drug, the price shown is the full cash price.

[2]
This plan does not cover this drug at the selected frequency, so the price shown represents the full cash
price.