IRBESARTAN + HYDROCHLOROTHIAZIDE

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: $22.68	Max safety net: $24.22	General Patient Charge: $25.00
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 300/25
Abisart HCTZ 300/25
IRBESARTAN HCTZ-WGR 300/25
Irbesartan/HCT Sandoz
Avapro HCT 300/25 *Additional charge for this brand is $7.68			DPMQ: $30.36	Max safety net: $24.22	General Patient Charge: $32.68
Karvezide 300/25 *Additional charge for this brand is $7.68			DPMQ: $30.36	Max safety net: $24.22	General Patient Charge: $32.68

13545X

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: $22.04	Max safety net: $23.58	General Patient Charge: $25.00
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 300/12.5
Abisart HCTZ 300/12.5
IRBESARTAN HCTZ-WGR 300/12.5
Irbesartan/HCT Sandoz
Avapro HCT 300/12.5 *Additional charge for this brand is $7.66			DPMQ: $29.70	Max safety net: $23.58	General Patient Charge: $32.66
Karvezide 300/12.5 *Additional charge for this brand is $7.66			DPMQ: $29.70	Max safety net: $23.58	General Patient Charge: $32.66

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: $19.84	Max safety net: $21.38	General Patient Charge: $24.17
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 $7.62			DPMQ: $27.46	Max safety net: $21.38	General Patient Charge: $31.79
Karvezide 150/12.5 *Additional charge for this brand is $7.62			DPMQ: $27.46	Max safety net: $21.38	General Patient Charge: $31.79

2136K

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: $18.52	Max safety net: $20.06	General Patient Charge: $22.85
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 300/25
Abisart HCTZ 300/25
IRBESARTAN HCTZ-WGR 300/25
Irbesartan/HCT Sandoz
Avapro HCT 300/25 *Additional charge for this brand is $3.84			DPMQ: $22.36	Max safety net: $20.06	General Patient Charge: $26.69
Karvezide 300/25 *Additional charge for this brand is $3.84			DPMQ: $22.36	Max safety net: $20.06	General Patient Charge: $26.69

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: $17.10	Max safety net: $18.64	General Patient Charge: $21.43
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 $3.81			DPMQ: $20.91	Max safety net: $18.64	General Patient Charge: $25.24
Karvezide 150/12.5 *Additional charge for this brand is $3.81			DPMQ: $20.91	Max safety net: $18.64	General Patient Charge: $25.24

8405J

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: $18.20	Max safety net: $19.74	General Patient Charge: $22.53
Available brands
APO-Irbesartan HCTZ
AVSARTAN HCT 300/12.5
Abisart HCTZ 300/12.5
IRBESARTAN HCTZ-WGR 300/12.5
Irbesartan/HCT Sandoz
Avapro HCT 300/12.5 *Additional charge for this brand is $3.83			DPMQ: $22.03	Max safety net: $19.74	General Patient Charge: $26.36
Karvezide 300/12.5 *Additional charge for this brand is $3.83			DPMQ: $22.03	Max safety net: $19.74	General Patient Charge: $26.36