AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5285E)

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
5285E
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Hypertension
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $25.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 5/160/12.5
Exforge HCT 5/160/12.5
*Additional charge for this brand is $12.00
 DPMQ: $37.32 Max safety net: $25.00 General Patient Charge: $37.00