Page 29 - Rx Drug Plan review for John

You may have to pay the full cost for drugs. Choose an in-network pharmacy to get drugs at a
lower cost. Find an in-network pharmacy.

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

Carvedilol 25mg
tablet $125.51 $125.51 $125.51 $125.51 $125.51

Diltiazem
hydrochloride
240mg capsule $48.18 $48.18 $48.18 $48.18 $48.18
extended release 24
hour

Febuxostat 40mg
tablet $348.92 $348.92 $348.92 $348.92 $348.92

Hydrochlorothiazide
$4.84 $4.84 $4.84 $4.84 $4.84
50mg tablet

Metformin
hydrochloride $84.82 $84.82 $84.82 $84.82 $84.82
1000mg tablet

Multaq 400mg
tablet $829.60 $829.60 $829.60 $829.60 $829.60

Olmesartan
medoxomil 40mg $280.70 $280.70 $280.70 $280.70 $280.70
tablet