LISINOPRIL

LISINOPRIL (13402J)

lisinopril 20 mg tablet, 30
13402J
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: $21.96 Max safety net: $23.44 General Patient Charge: $25.00
Available brands
APO-Lisinopril
Fibsol 20
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 20
Zestril
*Additional charge for this brand is $9.66
 DPMQ: $31.62 Max safety net: $23.44 General Patient Charge: $34.66

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 (13584Y)

lisinopril 10 mg tablet, 30
13584Y
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: $21.32 Max safety net: $22.80 General Patient Charge: $25.00
Available brands
APO-Lisinopril
Fibsol 10
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 10
Zestril
*Additional charge for this brand is $9.68
 DPMQ: $31.00 Max safety net: $22.80 General Patient Charge: $34.68

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

LISINOPRIL (2457H)

lisinopril 10 mg tablet, 30
2457H
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: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
APO-Lisinopril
Fibsol 10
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 10
Zestril
*Additional charge for this brand is $4.84
 DPMQ: $22.39 Max safety net: $19.03 General Patient Charge: $26.66

LISINOPRIL (2458J)

lisinopril 20 mg tablet, 30
2458J
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: $17.87 Max safety net: $19.35 General Patient Charge: $22.14
Available brands
APO-Lisinopril
Fibsol 20
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 20
Zestril
*Additional charge for this brand is $4.83
 DPMQ: $22.70 Max safety net: $19.35 General Patient Charge: $26.97