OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (10005N)

olmesartan medoxomil 20 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
10005N
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: 30 # of repeats: 5 DPMQ: $19.78 Max safety net: $21.26 General Patient Charge: $24.05
Available brands
APO-Olmesartan/Amlodipine/HCTZ 20/5/12.5
Olamlo HCT 20/5/12.5
Sevikar HCT 20/5/12.5
*Additional charge for this brand is $4.00
 DPMQ: $23.78 Max safety net: $21.26 General Patient Charge: $28.05

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13481M)

olmesartan medoxomil 20 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
13481M
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: 60 # of repeats: 5 DPMQ: $25.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 20/5/12.5
Olamlo HCT 20/5/12.5
Sevikar HCT 20/5/12.5
*Additional charge for this brand is $8.00
 DPMQ: $33.78 Max safety net: $25.00 General Patient Charge: $33.00