OLMESARTAN + HYDROCHLOROTHIAZIDE

OLMESARTAN + HYDROCHLOROTHIAZIDE (13447R)

olmesartan medoxomil 20 mg + hydrochlorothiazide 12.5 mg tablet, 30
13447R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
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: $22.84 Max safety net: $24.38 General Patient Charge: $25.00
Available brands
APO-Olmesartan/HCTZ 20/12.5
APX-Olmesartan/HCTZ
OLMERTAN COMBI 20/12.5
OLMESARTAN HCTZ-WGR 20/12.5
Olmesartan HCT - MYL 20/12.5
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 20/12.5
Olmetec Plus
*Additional charge for this brand is $5.68
 DPMQ: $28.52 Max safety net: $24.38 General Patient Charge: $30.68

OLMESARTAN + HYDROCHLOROTHIAZIDE (13601W)

olmesartan medoxomil 40 mg + hydrochlorothiazide 12.5 mg tablet, 30
13601W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
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: $24.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/HCTZ 40/12.5
APX-Olmesartan/HCTZ
OLMERTAN COMBI 40/12.5
OLMESARTAN HCTZ-WGR 40/12.5
Olmesartan HCT - MYL 40/12.5
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 40/12.5
Olmetec Plus
*Additional charge for this brand is $7.42
 DPMQ: $31.70 Max safety net: $25.00 General Patient Charge: $32.42

OLMESARTAN + HYDROCHLOROTHIAZIDE (13602X)

olmesartan medoxomil 40 mg + hydrochlorothiazide 25 mg tablet, 30
13602X
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
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: $25.50 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/HCTZ 40/25
APX-Olmesartan/HCTZ
OLMERTAN COMBI 40/25
OLMESARTAN HCTZ-WGR 40/25
Olmesartan HCT - MYL 40/25
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 40/25
Olmetec Plus
*Additional charge for this brand is $7.48
 DPMQ: $32.98 Max safety net: $25.00 General Patient Charge: $32.48

OLMESARTAN + HYDROCHLOROTHIAZIDE (2161R)

olmesartan medoxomil 20 mg + hydrochlorothiazide 12.5 mg tablet, 30
2161R
Body System:
Manner of administration:Oral
General Schedule
No restrictions
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: $18.60 Max safety net: $20.14 General Patient Charge: $22.93
Available brands
APO-Olmesartan/HCTZ 20/12.5
APX-Olmesartan/HCTZ
OLMERTAN COMBI 20/12.5
OLMESARTAN HCTZ-WGR 20/12.5
Olmesartan HCT - MYL 20/12.5
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 20/12.5
Olmetec Plus
*Additional charge for this brand is $2.84
 DPMQ: $21.44 Max safety net: $20.14 General Patient Charge: $25.77

OLMESARTAN + HYDROCHLOROTHIAZIDE (2166B)

olmesartan medoxomil 40 mg + hydrochlorothiazide 12.5 mg tablet, 30
2166B
Body System:
Manner of administration:Oral
General Schedule
No restrictions
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: $19.32 Max safety net: $20.86 General Patient Charge: $23.65
Available brands
APO-Olmesartan/HCTZ 40/12.5
APX-Olmesartan/HCTZ
OLMERTAN COMBI 40/12.5
OLMESARTAN HCTZ-WGR 40/12.5
Olmesartan HCT - MYL 40/12.5
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 40/12.5
Olmetec Plus
*Additional charge for this brand is $3.71
 DPMQ: $23.03 Max safety net: $20.86 General Patient Charge: $27.36

OLMESARTAN + HYDROCHLOROTHIAZIDE (2170F)

olmesartan medoxomil 40 mg + hydrochlorothiazide 25 mg tablet, 30
2170F
Body System:
Manner of administration:Oral
General Schedule
No restrictions
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: $19.93 Max safety net: $21.47 General Patient Charge: $24.26
Available brands
APO-Olmesartan/HCTZ 40/25
APX-Olmesartan/HCTZ
OLMERTAN COMBI 40/25
OLMESARTAN HCTZ-WGR 40/25
Olmesartan HCT - MYL 40/25
Olmesartan/HCT Sandoz
Pharmacor Olmesartan HCTZ 40/25
Olmetec Plus
*Additional charge for this brand is $3.74
 DPMQ: $23.67 Max safety net: $21.47 General Patient Charge: $28.00