| NAME |
HYDRALAZINE HCL 37.5MG/ISOSORBIDE DINITRATE 20MG TAB |
| VA GENERIC NAME |
HYDRALAZINE/ISOSORBIDE |
| DOSAGE FORM |
TAB |
| FORMULARY DESIGNATOR |
PA-F |
| FORMULARY DESIGNATOR TEXT |
Restricted to HFrEF as an adjunct to standard therapy in self-identified black patients
|
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| SINGLE/MULTI SOURCE PRODUCT |
Single source |
| NATIONAL FORMULARY NAME |
HYDRALAZINE/ISOSORBIDE TAB |
| CREATE DEFAULT POSSIBLE DOSAGE |
YES |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 3
- COPAY EFFECTIVE DATE: 2017-02-27 00:00:00
- COPAY END DATE: 2022-04-20 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2022-04-21 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
HYDRALAZINE 37.5/ISOSORBIDE DIN 20MG TAB |
| VA PRODUCT IDENTIFIER |
H0473 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
TAB |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4024885 |
| EFFECTIVE DATE/TIME |
-
- 2006-01-24 00:00:00
- STATUS: ACTIVE
|
