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

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13482N)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 12.5 mg tablet, 30
13482N
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: $32.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/12.5
Olamlo HCT 40/10/12.5
Sevikar HCT 40/10/12.5
*Additional charge for this brand is $8.52
 DPMQ: $40.80 Max safety net: $25.00 General Patient Charge: $33.52

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13512E)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 25 mg tablet, 30
13512E
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: $34.58 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/25 tablet
Olamlo HCT 40/5/25
Sevikar HCT 40/5/25
*Additional charge for this brand is $8.00
 DPMQ: $42.58 Max safety net: $25.00 General Patient Charge: $33.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13513F)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
13513F
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: $31.46 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/12.5 tablet
Olamlo HCT 40/5/12.5
Sevikar HCT 40/5/12.5
*Additional charge for this brand is $8.00
 DPMQ: $39.46 Max safety net: $25.00 General Patient Charge: $33.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (14002Y)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 25 mg tablet, 30
14002Y
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: $35.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/25
Olamlo HCT 40/10/25
Sevikar HCT 40/10/25
*Additional charge for this brand is $8.00
 DPMQ: $43.34 Max safety net: $25.00 General Patient Charge: $33.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2836G)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 12.5 mg tablet, 30
2836G
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: $23.03 Max safety net: $24.51 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/12.5
Olamlo HCT 40/10/12.5
Sevikar HCT 40/10/12.5
*Additional charge for this brand is $4.26
 DPMQ: $27.29 Max safety net: $24.51 General Patient Charge: $29.26

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2864R)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 25 mg tablet, 30
2864R
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: $24.18 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/25 tablet
Olamlo HCT 40/5/25
Sevikar HCT 40/5/25
*Additional charge for this brand is $4.00
 DPMQ: $28.18 Max safety net: $25.00 General Patient Charge: $29.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2880N)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
2880N
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: $22.62 Max safety net: $24.10 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/12.5 tablet
Olamlo HCT 40/5/12.5
Sevikar HCT 40/5/12.5
*Additional charge for this brand is $4.00
 DPMQ: $26.62 Max safety net: $24.10 General Patient Charge: $29.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2953K)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 25 mg tablet, 30
2953K
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: $24.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/25
Olamlo HCT 40/10/25
Sevikar HCT 40/10/25
*Additional charge for this brand is $4.00
 DPMQ: $28.56 Max safety net: $25.00 General Patient Charge: $29.00