| NAME |
DALFAMPRIDINE 10MG TAB,SA |
| VA GENERIC NAME |
DALFAMPRIDINE |
| DOSAGE FORM |
TAB,SA |
| FDA MED GUIDE |
Dalfampridine_XR_(Generic)_(2021).pdf |
| FORMULARY DESIGNATOR |
PA-F |
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
10 |
| SINGLE/MULTI SOURCE PRODUCT |
Single source |
| UNITS |
MG |
| NATIONAL FORMULARY NAME |
DALFAMPRIDINE TAB,SA |
| 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: 2018-09-23 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2018-09-24 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
DALFAMPRIDINE 10MG SA TAB |
| VA PRODUCT IDENTIFIER |
D0841 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
TAB |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4029686 |
| EFFECTIVE DATE/TIME |
-
- 2010-03-09 00:00:00
- STATUS: ACTIVE
|
