AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/25/160 mg Tablet, Film Coated
Also known as Amlodipine Besylate Valsartan Hydrochlorothiazide. Coverage in Wisconsin (CMS PDP Region 16).
6 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 1–3.
Lowest 30-day cost $2.00 at a preferred pharmacy. 4 of 6 plans apply a prior authorization, step therapy or quantity limit.
43 Medicare Advantage plans in WI do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. WI: 43 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $1.3002 | $3.903 units |
|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $3.1155 | $9.353 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $3.0248 | $9.073 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $6.4948 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $5.7748 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $7.5514 | $22.653 units |
|
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.