FOLLITROPIN ALFA 450UNIT/0.75ML INJ,PEN,0.75ML (24048)    VA PRODUCT (50.68)

Name Value
NAME FOLLITROPIN ALFA 450UNIT/0.75ML INJ,PEN,0.75ML
VA GENERIC NAME FOLLITROPIN
DOSAGE FORM INJ
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
SINGLE/MULTI SOURCE PRODUCT Single source
UNITS UNIT/0.75ML
NATIONAL FORMULARY NAME FOLLITROPIN INJ
CREATE DEFAULT POSSIBLE DOSAGE YES
CODING SYSTEM
  • RxNorm
    CODE:
COPAY TIER
  • COPAY TIER LEVEL:   3
    COPAY EFFECTIVE DATE:   2017-02-27 00:00:00
PGX ELIGIBLE NO
PGX SUPPRESSED NO
VA PRINT NAME FOLLITROPIN ALFA 450UNIT/0.75ML INJ PEN
VA PRODUCT IDENTIFIER F0530
TRANSMIT TO CMOP YES
VA DISPENSE UNIT EA
MASTER ENTRY FOR VUID YES
VUID 4032575
EFFECTIVE DATE/TIME
  • 2013-07-23 00:00:00
    STATUS:   ACTIVE