| NAME |
AMPHOTERICIN B LIPOSOME 50MG/VIL INJ |
| VA GENERIC NAME |
AMPHOTERICIN B |
| DOSAGE FORM |
INJ |
| FORMULARY DESIGNATOR |
R |
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
50 |
| SINGLE/MULTI SOURCE PRODUCT |
Single source |
| UNITS |
MG/VIAL |
| DSS NUMBER |
10 |
| NATIONAL FORMULARY NAME |
AMPHOTERICIN B INJ |
| CREATE DEFAULT POSSIBLE DOSAGE |
NO |
| POSSIBLE DOSAGES TO CREATE |
No Possible Dosages |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 3
- COPAY EFFECTIVE DATE: 2017-02-27 00:00:00
- COPAY END DATE: 2022-02-23 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2022-02-24 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
AMPHOTERICIN B LIPOSOME 50MG/VIL INJ |
| VA PRODUCT IDENTIFIER |
A0768 |
| TRANSMIT TO CMOP |
NO |
| VA DISPENSE UNIT |
VI |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4001707 |
| EFFECTIVE DATE/TIME |
-
- 2005-03-10 00:00:00
- STATUS: ACTIVE
|
