TELMISARTAN + HYDROCHLOROTHIAZIDE

TELMISARTAN + HYDROCHLOROTHIAZIDE (13546Y)

telmisartan 40 mg + hydrochlorothiazide 12.5 mg tablet, 28
13546Y
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: $19.46 Max safety net: $20.94 General Patient Charge: $23.73
Available brands
APO-Telmisartan HCTZ 40/12.5
Mizart HCT 40/12.5 mg
TELMISARTAN HCTZ-WGR 40/12.5
Telmisartan/HCT Sandoz
Teltartan HCT 40/12.5
Micardis Plus 40/12.5 mg
*Additional charge for this brand is $20.00
 DPMQ: $39.46 Max safety net: $20.94 General Patient Charge: $43.73

TELMISARTAN + HYDROCHLOROTHIAZIDE (8622T)

telmisartan 40 mg + hydrochlorothiazide 12.5 mg tablet, 28
8622T
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: $16.62 Max safety net: $18.10 General Patient Charge: $20.89
Available brands
APO-Telmisartan HCTZ 40/12.5
Mizart HCT 40/12.5 mg
TELMISARTAN HCTZ-WGR 40/12.5
Telmisartan/HCT Sandoz
Teltartan HCT 40/12.5
Micardis Plus 40/12.5 mg
*Additional charge for this brand is $10.00
 DPMQ: $26.62 Max safety net: $18.10 General Patient Charge: $30.89