OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (13513F)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
13513F
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: $31.46 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/12.5 tablet
Olamlo HCT 40/5/12.5
Sevikar HCT 40/5/12.5
*Additional charge for this brand is $8.00
 DPMQ: $39.46 Max safety net: $25.00 General Patient Charge: $33.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2880N)

olmesartan medoxomil 40 mg + amlodipine 5 mg + hydrochlorothiazide 12.5 mg tablet, 30
2880N
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: $22.62 Max safety net: $24.10 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/5/12.5 tablet
Olamlo HCT 40/5/12.5
Sevikar HCT 40/5/12.5
*Additional charge for this brand is $4.00
 DPMQ: $26.62 Max safety net: $24.10 General Patient Charge: $29.00