| NAME |
ELETRIPTAN 40MG TAB,PKG,6 |
| VA GENERIC NAME |
ELETRIPTAN |
| DOSAGE FORM |
TAB |
| FORMULARY DESIGNATOR TEXT |
Dispense limit of 18 doses of oral triptans per month
|
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
40 |
| SINGLE/MULTI SOURCE PRODUCT |
Multisource |
| UNITS |
MG |
| NATIONAL FORMULARY NAME |
ELETRIPTAN TAB |
| CREATE DEFAULT POSSIBLE DOSAGE |
NO |
| POSSIBLE DOSAGES TO CREATE |
1x Possible Dosage |
| PACKAGE |
Both Inpatient and Outpatient |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 3
- COPAY EFFECTIVE DATE: 2017-02-27 00:00:00
- COPAY END DATE: 2017-08-31 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2017-09-01 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
ELETRIPTAN 40MG TAB 6 PKG |
| VA PRODUCT IDENTIFIER |
E0363 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
PKG |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4016506 |
| EFFECTIVE DATE/TIME |
-
- 2005-03-10 00:00:00
- STATUS: ACTIVE
|
