Page 23 - APPENDICES for Vic Bosiger
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CVS Pharmacy #07948
Standard in-network pharmacy
Omeprazole 20mg capsule
delayed release $53.09
Prasugrel 10mg tablet $188.04
Rosuvastatin calcium 40mg
tablet $19.75
Victoza 18mg/3ml solution pen
injector $1,577.82
Total yearly drug cost $2,948.38
ESTIMATED TOTAL DRUG + PREMIUM COST
CVS Pharmacy #07948
Standard in-network pharmacy
Total yearly drug + premium cost $2,948.38
When you'll meet your You won't meet your deductible in 2022
deductible
