AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE

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 (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