AMLODIPINE + VALSARTAN

AMLODIPINE + VALSARTAN (13454D)

amlodipine 10 mg + valsartan 160 mg tablet, 28
13454D
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: $34.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 10/160
Exforge 10/160
*Additional charge for this brand is $16.00
 DPMQ: $50.88 Max safety net: $25.00 General Patient Charge: $41.00

AMLODIPINE + VALSARTAN (9377M)

amlodipine 10 mg + valsartan 160 mg tablet, 28
9377M
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: $24.33 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Amlodipine/Valsartan Novartis 10/160
Exforge 10/160
*Additional charge for this brand is $8.00
 DPMQ: $32.33 Max safety net: $25.00 General Patient Charge: $33.00