Page 26 - APPENDICES for Vic Bosiger
P. 26
Cost
Cost in
Retail Cost after after
coverage
cost deductible coverage
gap
gap
Prasugrel 10mg tablet $42.07 $42.07 $10.52 $3.95
Rosuvastatin calcium 40mg
tablet $5.23 $0.00 $0.00 $3.95
Victoza 18mg/3ml solution pen
injector $1,086.36 $47.00 $271.59 $54.32
Monthly totals $1,765.48 $169.51 $433.66 $125.27
COSTS BY DRUG TIER
Plans group their drug lists into tiers. The drug costs below show how much you'll pay for drugs in each tier
based on the coverage phase you're in.
Learn more about drug tiers.
