| NAME |
FOLLITROPIN ALFA 450 UNIT/VIL INJ |
| VA GENERIC NAME |
FOLLITROPIN |
| DOSAGE FORM |
INJ,LYPHL |
| 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/VIL |
| NATIONAL FORMULARY NAME |
FOLLITROPIN INJ,LYPHL |
| CREATE DEFAULT POSSIBLE DOSAGE |
NO |
| POSSIBLE DOSAGES TO CREATE |
No Possible Dosages |
| CODING SYSTEM |
|
| 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 450 UNIT/VIL INJ |
| VA PRODUCT IDENTIFIER |
F0576 |
| TRANSMIT TO CMOP |
NO |
| VA DISPENSE UNIT |
VI |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4034851 |
| EFFECTIVE DATE/TIME |
-
- 2015-09-30 00:00:00
- STATUS: ACTIVE
|
