Page 32 - APPENDICES for Vic Bosiger

Package Quantity Frequency Brand/Generic

Nitroglycerin 0.4mg Every
tablet sublingual 50 month Generic

Omeprazole 20mg Every
capsule delayed release 30 month Generic

Every
Prasugrel 10mg tablet 30 Generic
month

Rosuvastatin calcium Every
40mg tablet 30 month Generic

3ml pen
Victoza 18mg/3ml Every
solution pen injector (sold in 1 month Brand
pack of 3)

PART B DRUGS

These are drugs you usually get at a doctor's o ce or hospital outpatient setting, like the u shot,
chemotherapy, or other shots.

Chemotherapy drugs In-network: 20% coinsurance Limits apply

Other Part B drugs In-network: 0-20% Limits apply

coinsurance

Extra bene ts