OLMESARTAN + HYDROCHLOROTHIAZIDE

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: $23.94 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 $7.72
 DPMQ: $31.66 Max safety net: $25.00 General Patient Charge: $32.72

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: $18.86 Max safety net: $20.34 General Patient Charge: $23.13
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 $3.86
 DPMQ: $22.72 Max safety net: $20.34 General Patient Charge: $26.99