LISINOPRIL

LISINOPRIL (13583X)

lisinopril 5 mg tablet, 30
13583X
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: $19.24 Max safety net: $20.72 General Patient Charge: $23.51
Available brands
APO-Lisinopril
Fibsol 5
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 5
Zestril
*Additional charge for this brand is $9.64
 DPMQ: $28.88 Max safety net: $20.72 General Patient Charge: $33.15

LISINOPRIL (2456G)

lisinopril 5 mg tablet, 30
2456G
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: $16.51 Max safety net: $17.99 General Patient Charge: $20.78
Available brands
APO-Lisinopril
Fibsol 5
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 5
Zestril
*Additional charge for this brand is $4.82
 DPMQ: $21.33 Max safety net: $17.99 General Patient Charge: $25.60