Page 50 - APPENDICES for Vic Bosiger
P. 50
Cost
Cost Cost in
Retail Cost after after
before coverage
cost deductible coverage
deductible gap
gap
Metformin
hydrochloride
1000mg $9.91 $5.00 $5.00 $2.48 $3.95
tablet
Nitroglycerin
0.4mg tablet $15.70 $15.00 $15.00 $3.93 $3.95
sublingual
Omeprazole
20mg capsule
delayed $6.54 $5.00 $5.00 $1.63 $3.95
release
Prasugrel
10mg tablet $35.66 $15.00 $15.00 $8.92 $3.95
Rosuvastatin
calcium $24.59 $5.00 $5.00 $6.15 $3.95
40mg tablet
Victoza
18mg/3ml
solution pen $1,022.69 $47.00 $47.00 $255.67 $51.13
injector
Monthly
totals $1,712.46 $170.12 $170.12 $428.12 $123.57
COSTS BY DRUG TIER
