TELMISARTAN + HYDROCHLOROTHIAZIDE

TELMISARTAN + HYDROCHLOROTHIAZIDE (13574K)

telmisartan 80 mg + hydrochlorothiazide 12.5 mg tablet, 28
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: $22.40 Max safety net: $23.88 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 $20.00
 DPMQ: $42.40 Max safety net: $23.88 General Patient Charge: $45.00

TELMISARTAN + HYDROCHLOROTHIAZIDE (8623W)

telmisartan 80 mg + hydrochlorothiazide 12.5 mg tablet, 28
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: $18.09 Max safety net: $19.57 General Patient Charge: $22.36
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 $10.00
 DPMQ: $28.09 Max safety net: $19.57 General Patient Charge: $32.36