Page 32 - 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 $17.91 $17.91 $17.91 $4.48 $3.95

Diltiazem
hydrochloride
240mg capsule $40.98 $40.98 $40.98 $10.25 $3.95
extended release 24

hour

Febuxostat 40mg
tablet $44.46 $44.46 $44.46 $11.11 $3.95

Hydrochlorothiazide
50mg tablet [ 2 ] $5.59 $5.59 $5.59 $5.59 $5.59

Metformin

hydrochloride $15.06 $15.00 $15.00 $3.77 $3.95
1000mg tablet

Multaq 400mg
tablet $738.28 $738.28 $45.00 $184.57 $36.91

[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.