TELMISARTAN + 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: 56	# of repeats: 5	DPMQ: $20.08	Max safety net: $21.62	General Patient Charge: $24.41
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 $19.16			DPMQ: $39.24	Max safety net: $21.62	General Patient Charge: $43.57

13574K

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: $22.84	Max safety net: $24.38	General Patient Charge: $25.00
Available brands
APO-Telmisartan HCTZ 80/12.5
Mizart HCT 80/12.5 mg
TELMISARTAN HCTZ-WGR 80/12.5
Telmisartan/HCT Sandoz
Teltartan HCT 80/12.5
Micardis Plus 80/12.5 mg *Additional charge for this brand is $19.26			DPMQ: $42.10	Max safety net: $24.38	General Patient Charge: $44.26

13607E

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: $23.46	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
APO-Telmisartan HCTZ 80/25
Mizart HCT 80/25 mg
TELMISARTAN HCTZ-WGR 80/25
Telmisartan/HCT Sandoz
Teltartan HCT 80/25
Micardis Plus 80/25 mg *Additional charge for this brand is $19.30			DPMQ: $42.76	Max safety net: $25.00	General Patient Charge: $44.30

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: $17.22	Max safety net: $18.76	General Patient Charge: $21.55
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 $9.58			DPMQ: $26.80	Max safety net: $18.76	General Patient Charge: $31.13

8623W

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: $18.60	Max safety net: $20.14	General Patient Charge: $22.93
Available brands
APO-Telmisartan HCTZ 80/12.5
Mizart HCT 80/12.5 mg
TELMISARTAN HCTZ-WGR 80/12.5
Telmisartan/HCT Sandoz
Teltartan HCT 80/12.5
Micardis Plus 80/12.5 mg *Additional charge for this brand is $9.63			DPMQ: $28.23	Max safety net: $20.14	General Patient Charge: $32.56

9381R

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: $18.91	Max safety net: $20.45	General Patient Charge: $23.24
Available brands
APO-Telmisartan HCTZ 80/25
Mizart HCT 80/25 mg
TELMISARTAN HCTZ-WGR 80/25
Telmisartan/HCT Sandoz
Teltartan HCT 80/25
Micardis Plus 80/25 mg *Additional charge for this brand is $9.65			DPMQ: $28.56	Max safety net: $20.45	General Patient Charge: $32.89