| NAME |
FOLLITROPIN ALFA 75UNT/AMP INJ |
| VA GENERIC NAME |
FOLLITROPIN |
| DOSAGE FORM |
INJ |
| FORMULARY DESIGNATOR |
PA-F |
| FORMULARY DESIGNATOR TEXT |
Restricted to non-VA infertility referral/VA infertility Specialist
|
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
75 |
| INACTIVATION DATE |
2008-03-19 00:00:00 |
| UNITS |
UNIT/AMP |
| DSS NUMBER |
2 |
| NATIONAL FORMULARY NAME |
FOLLITROPIN INJ |
| CREATE DEFAULT POSSIBLE DOSAGE |
YES |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2017-02-27 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
FOLLITROPIN ALFA 75UNT/AMP INJ |
| VA PRODUCT IDENTIFIER |
F0164 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
AMP |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4013153 |
| EFFECTIVE DATE/TIME |
-
- 2005-03-10 00:00:00
- STATUS: ACTIVE
-
- 2008-03-19 00:00:00
- STATUS: INACTIVE
|
