OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (14002Y)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 25 mg tablet, 30
14002Y
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: $35.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/25
Olamlo HCT 40/10/25
Sevikar HCT 40/10/25
*Additional charge for this brand is $8.00
 DPMQ: $43.34 Max safety net: $25.00 General Patient Charge: $33.00

OLMESARTAN + AMLODIPINE + HYDROCHLOROTHIAZIDE (2953K)

olmesartan medoxomil 40 mg + amlodipine 10 mg + hydrochlorothiazide 25 mg tablet, 30
2953K
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: $24.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Olmesartan/Amlodipine/HCTZ 40/10/25
Olamlo HCT 40/10/25
Sevikar HCT 40/10/25
*Additional charge for this brand is $4.00
 DPMQ: $28.56 Max safety net: $25.00 General Patient Charge: $29.00