AMLODIPINE + VALSARTAN

AMLODIPINE + VALSARTAN (13421J)

amlodipine 5 mg + valsartan 80 mg tablet, 28
13421J
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: $29.76 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 5/80
Exforge 5/80
*Additional charge for this brand is $16.00
 DPMQ: $45.76 Max safety net: $25.00 General Patient Charge: $41.00

AMLODIPINE + VALSARTAN (9375K)

amlodipine 5 mg + valsartan 80 mg tablet, 28
9375K
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: $21.77 Max safety net: $23.25 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 5/80
Exforge 5/80
*Additional charge for this brand is $8.00
 DPMQ: $29.77 Max safety net: $23.25 General Patient Charge: $33.00