AMLODIPINE + VALSARTAN

AMLODIPINE + VALSARTAN (13604B)

amlodipine 5 mg + valsartan 320 mg tablet, 28
13604B
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
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: $38.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 5/320
Exforge 5/320
*Additional charge for this brand is $15.52
 DPMQ: $54.32 Max safety net: $25.00 General Patient Charge: $40.52

AMLODIPINE + VALSARTAN (5459H)

amlodipine 5 mg + valsartan 320 mg tablet, 28
5459H
Body System:
Manner of administration:Oral
General Schedule
No restrictions
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: $26.58 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 5/320
Exforge 5/320
*Additional charge for this brand is $7.76
 DPMQ: $34.34 Max safety net: $25.00 General Patient Charge: $32.76