Page 47 - APPENDICES for Vic Bosiger
P. 47
CVS Pharmacy #07948
Standard in-network pharmacy
Omeprazole 20mg capsule
delayed release $41.27
Prasugrel 10mg tablet $100.43
Rosuvastatin calcium 40mg
tablet $59.35
Victoza 18mg/3ml solution pen
injector $1,551.88
Total yearly drug cost $2,973.24
ESTIMATED TOTAL DRUG + PREMIUM COST
CVS Pharmacy #07948
Standard in-network pharmacy
Total yearly drug + premium cost $2,973.24
When you'll meet your March 2022
deductible
When you'll enter the March 2022
coverage gap
When you'll get out of the
coverage gap July 2022
