FOLLITROPIN ALFA 450UNT/ML INJ,SYR,1.5ML (17350)    VA PRODUCT (50.68)

Name Value
NAME FOLLITROPIN ALFA 450UNT/ML INJ,SYR,1.5ML
VA GENERIC NAME FOLLITROPIN
DOSAGE FORM INJ,SOLN
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 450
INACTIVATION DATE 2005-11-03 00:00:00
UNITS UNIT/ML
NATIONAL FORMULARY NAME FOLLITROPIN INJ,SOLN
CREATE DEFAULT POSSIBLE DOSAGE YES
CODING SYSTEM
  • RxNorm
    CODE:
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 450UNT/ML INJ,SYR,1.5ML
VA PRODUCT IDENTIFIER F0357
TRANSMIT TO CMOP YES
VA DISPENSE UNIT SYR
MASTER ENTRY FOR VUID YES
VUID 4024782
EFFECTIVE DATE/TIME
  • 2005-11-03 00:00:00
    STATUS:   INACTIVE
  • 2005-11-03 00:00:00
    STATUS:   INACTIVE