AMLODIPINE + VALSARTAN + HYDROCHLOROTHIAZIDE
amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $40.94 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $64.94 | Max safety net: $25.00 | General Patient Charge: $49.00 | ||
amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $36.86 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $60.86 | Max safety net: $25.00 | General Patient Charge: $49.00 | ||
amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $37.90 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $53.90 | Max safety net: $25.00 | General Patient Charge: $41.00 | ||
amlodipine 10 mg + valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $45.48 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $61.48 | Max safety net: $25.00 | General Patient Charge: $41.00 | ||
amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $39.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $55.88 | Max safety net: $25.00 | General Patient Charge: $41.00 | ||
amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $25.32 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $37.32 | Max safety net: $25.00 | General Patient Charge: $37.00 | ||
amlodipine 5 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $26.83 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $34.83 | Max safety net: $25.00 | General Patient Charge: $33.00 | ||
amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 12.5 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $25.84 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $33.84 | Max safety net: $25.00 | General Patient Charge: $33.00 | ||
amlodipine 10 mg + valsartan 160 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $27.36 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $39.36 | Max safety net: $25.00 | General Patient Charge: $37.00 | ||
amlodipine 10 mg + valsartan 320 mg + hydrochlorothiazide 25 mg tablet, 28
Manner of administration:Oral
Restriction
Indication: Hypertension
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: $29.63 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $37.63 | Max safety net: $25.00 | General Patient Charge: $33.00 | ||