| NAME |
MEMANTINE HCL 21MG CAP,SA |
| VA GENERIC NAME |
MEMANTINE |
| DOSAGE FORM |
CAP,SA |
| ACTIVE INGREDIENTS |
|
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
21 |
| SINGLE/MULTI SOURCE PRODUCT |
Multisource |
| UNITS |
MG |
| NATIONAL FORMULARY NAME |
MEMANTINE CAP,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: 2018-03-31 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2018-04-01 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
MEMANTINE HCL 21MG SA CAP |
| VA PRODUCT IDENTIFIER |
M0997 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
CAP |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4032361 |
| EFFECTIVE DATE/TIME |
-
- 2013-05-15 00:00:00
- STATUS: ACTIVE
|
