AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (13390R)

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
13390R
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: 2 Max qty units: 56 # of repeats: 5 DPMQ: $40.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/160/25
Exforge HCT 10/160/25
*Additional charge for this brand is $24.00
 DPMQ: $64.94 Max safety net: $25.00 General Patient Charge: $49.00