VALSARTAN + HYDROCHLOROTHIAZIDE

VALSARTAN + HYDROCHLOROTHIAZIDE (13393X)

valsartan 80 mg + hydrochlorothiazide 12.5 mg tablet, 28
13393X
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: $27.30 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 80/12.5
Dilart HCT 80/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (13453C)

valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
13453C
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: $32.50 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 160/25
Dilart HCT 160/25

VALSARTAN + HYDROCHLOROTHIAZIDE (13455E)

valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
13455E
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: $36.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 320/25
Dilart HCT 320/25

VALSARTAN + HYDROCHLOROTHIAZIDE (13517K)

valsartan 320 mg + hydrochlorothiazide 12.5 mg tablet, 28
13517K
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: $34.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 320/12.5
Dilart HCT 320/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (13606D)

valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
13606D
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: $30.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 160/12.5
Dilart HCT 160/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (9372G)

valsartan 80 mg + hydrochlorothiazide 12.5 mg tablet, 28
9372G
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: $20.83 Max safety net: $22.37 General Patient Charge: $25.00
Available brands
Co-Diovan 80/12.5
Dilart HCT 80/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (9373H)

valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
9373H
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: $22.36 Max safety net: $23.90 General Patient Charge: $25.00
Available brands
Co-Diovan 160/12.5
Dilart HCT 160/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (9374J)

valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
9374J
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: $23.43 Max safety net: $24.97 General Patient Charge: $25.00
Available brands
Co-Diovan 160/25
Dilart HCT 160/25

VALSARTAN + HYDROCHLOROTHIAZIDE (9481B)

valsartan 320 mg + hydrochlorothiazide 12.5 mg tablet, 28
9481B
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: $24.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 320/12.5
Dilart HCT 320/12.5

VALSARTAN + HYDROCHLOROTHIAZIDE (9482C)

valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
9482C
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: $25.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Co-Diovan 320/25
Dilart HCT 320/25