IRBESARTAN + HYDROCHLOROTHIAZIDE

IRBESARTAN + HYDROCHLOROTHIAZIDE (13572H)

irbesartan 150 mg + hydrochlorothiazide 12.5 mg tablet, 30
13572H
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: 60 # of repeats: 5 DPMQ: $19.22 Max safety net: $20.70 General Patient Charge: $23.49
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 150/12.5
Abisart HCTZ 150/12.5
IRBESARTAN HCTZ-WGR 150/12.5
Irbesartan/HCT Sandoz
Avapro HCT 150/12.5
*Additional charge for this brand is $8.08
 DPMQ: $27.30 Max safety net: $20.70 General Patient Charge: $31.57
Karvezide 150/12.5
*Additional charge for this brand is $8.08
 DPMQ: $27.30 Max safety net: $20.70 General Patient Charge: $31.57

IRBESARTAN + HYDROCHLOROTHIAZIDE (8404H)

irbesartan 150 mg + hydrochlorothiazide 12.5 mg tablet, 30
8404H
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: 30 # of repeats: 5 DPMQ: $16.50 Max safety net: $17.98 General Patient Charge: $20.77
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 150/12.5
Abisart HCTZ 150/12.5
IRBESARTAN HCTZ-WGR 150/12.5
Irbesartan/HCT Sandoz
Avapro HCT 150/12.5
*Additional charge for this brand is $4.04
 DPMQ: $20.54 Max safety net: $17.98 General Patient Charge: $24.81
Karvezide 150/12.5
*Additional charge for this brand is $4.04
 DPMQ: $20.54 Max safety net: $17.98 General Patient Charge: $24.81