OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13512E)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 25 mg tablet, 30
13512E
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Hypertension
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: $34.52 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/25 tablet
Olamlo HCT 40/5/25
Sevikar HCT 40/5/25
*Additional charge for this brand is $7.76
 DPMQ: $42.28 Max safety net: $25.00 General Patient Charge: $32.76

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2864R)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 25 mg tablet, 30
2864R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Hypertension
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: $24.44 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/25 tablet
Olamlo HCT 40/5/25
Sevikar HCT 40/5/25
*Additional charge for this brand is $3.88
 DPMQ: $28.32 Max safety net: $25.00 General Patient Charge: $28.88