AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (13390R)

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
13390R
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: $40.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/160/25
Exforge HCT 10/160/25
*Additional charge for this brand is $23.28
 DPMQ: $63.96 Max safety net: $25.00 General Patient Charge: $48.28

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 (13514G)

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
13514G
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: $37.74 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/160/12.5
Exforge HCT 10/160/12.5
*Additional charge for this brand is $15.52
 DPMQ: $53.26 Max safety net: $25.00 General Patient Charge: $40.52

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (13573J)

amlodipine 10 mg + valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
13573J
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: $45.08 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/320/25
Exforge HCT 10/320/25
*Additional charge for this brand is $15.52
 DPMQ: $60.60 Max safety net: $25.00 General Patient Charge: $40.52

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (13603Y)

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
13603Y
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: $39.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 5/160/25
Exforge HCT 5/160/25
*Additional charge for this brand is $15.52
 DPMQ: $55.18 Max safety net: $25.00 General Patient Charge: $40.52

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

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5286F)

amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
5286F
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: $27.01 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 5/160/25
Exforge HCT 5/160/25
*Additional charge for this brand is $7.76
 DPMQ: $34.77 Max safety net: $25.00 General Patient Charge: $32.76

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5287G)

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
5287G
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: $26.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/160/12.5
Exforge HCT 10/160/12.5
*Additional charge for this brand is $7.76
 DPMQ: $33.81 Max safety net: $25.00 General Patient Charge: $32.76

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5288H)

amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
5288H
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: $27.52 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/160/25
Exforge HCT 10/160/25
*Additional charge for this brand is $11.64
 DPMQ: $39.16 Max safety net: $25.00 General Patient Charge: $36.64

AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE (5289J)

amlodipine 10 mg + valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
5289J
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: $29.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan/HCT Novartis 10/320/25
Exforge HCT 10/320/25
*Additional charge for this brand is $7.76
 DPMQ: $37.48 Max safety net: $25.00 General Patient Charge: $32.76