AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (13448T)

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
13448T
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: 56 # of repeats: 5 DPMQ: $36.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 5/160/12.5
Exforge HCT 5/160/12.5
*Additional charge for this brand is $23.28
 DPMQ: $60.00 Max safety net: $25.00 General Patient Charge: $48.28

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5285E)

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
5285E
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: 28 # of repeats: 5 DPMQ: $25.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 5/160/12.5
Exforge HCT 5/160/12.5
*Additional charge for this brand is $11.64
 DPMQ: $37.18 Max safety net: $25.00 General Patient Charge: $36.64