AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

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 (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