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: $20.17 Max safety net: $21.71 General Patient Charge: $24.50
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 $3.88
 DPMQ: $24.05 Max safety net: $21.71 General Patient Charge: $28.38

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: $25.98 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 $7.76
 DPMQ: $33.74 Max safety net: $25.00 General Patient Charge: $32.76

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 $8.28
 DPMQ: $40.56 Max safety net: $25.00 General Patient Charge: $33.28

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: $34.52 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 $7.76
 DPMQ: $42.28 Max safety net: $25.00 General Patient Charge: $32.76

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: $31.48 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 $7.76
 DPMQ: $39.24 Max safety net: $25.00 General Patient Charge: $32.76

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: $35.26 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 $7.76
 DPMQ: $43.02 Max safety net: $25.00 General Patient Charge: $32.76

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: $23.32 Max safety net: $24.86 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 $4.14
 DPMQ: $27.46 Max safety net: $24.86 General Patient Charge: $29.14

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: $24.44 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 $3.88
 DPMQ: $28.32 Max safety net: $25.00 General Patient Charge: $28.88

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: $22.92 Max safety net: $24.46 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 $3.88
 DPMQ: $26.80 Max safety net: $24.46 General Patient Charge: $28.88

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: $24.81 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 $3.88
 DPMQ: $28.69 Max safety net: $25.00 General Patient Charge: $28.88