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: $22.42 Max safety net: $23.96 General Patient Charge: $25.00
Available brands
APO-Lisinopril
Fibsol 20
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 20
Zestril
*Additional charge for this brand is $9.24
 DPMQ: $31.66 Max safety net: $23.96 General Patient Charge: $34.24

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: $19.86 Max safety net: $21.40 General Patient Charge: $24.19
Available brands
APO-Lisinopril
Fibsol 5
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 5
Zestril
*Additional charge for this brand is $9.12
 DPMQ: $28.98 Max safety net: $21.40 General Patient Charge: $33.31

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: $21.84 Max safety net: $23.38 General Patient Charge: $25.00
Available brands
APO-Lisinopril
Fibsol 10
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 10
Zestril
*Additional charge for this brand is $9.20
 DPMQ: $31.04 Max safety net: $23.38 General Patient Charge: $34.20

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: $17.11 Max safety net: $18.65 General Patient Charge: $21.44
Available brands
APO-Lisinopril
Fibsol 5
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 5
Zestril
*Additional charge for this brand is $4.56
 DPMQ: $21.67 Max safety net: $18.65 General Patient Charge: $26.00

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: $18.10 Max safety net: $19.64 General Patient Charge: $22.43
Available brands
APO-Lisinopril
Fibsol 10
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 10
Zestril
*Additional charge for this brand is $4.60
 DPMQ: $22.70 Max safety net: $19.64 General Patient Charge: $27.03

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: $18.39 Max safety net: $19.93 General Patient Charge: $22.72
Available brands
APO-Lisinopril
Fibsol 20
LISINOPRIL-WGR
Lisinopril Sandoz
Zinopril 20
Zestril
*Additional charge for this brand is $4.62
 DPMQ: $23.01 Max safety net: $19.93 General Patient Charge: $27.34