Page 70 - APPENDICES for Vic Bosiger
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CVS Pharmacy #07948
Preferred Preferred in-network pharmacy
Omeprazole 20mg capsule
delayed release $19.08
Prasugrel 10mg tablet $110.85
Rosuvastatin calcium 40mg
tablet $37.35
Victoza 18mg/3ml solution pen
injector $1,575.91
Total yearly drug cost $3,114.92
ESTIMATED TOTAL DRUG + PREMIUM COST
CVS Pharmacy #07948
Preferred Preferred in-network pharmacy
Total yearly drug + premium cost $3,114.92
When you'll meet your
You won't meet your deductible in 2022
deductible
