| NAME |
DOLUTEGRAVIR 50MG/RILPIVIRINE 25MG TAB |
| VA GENERIC NAME |
DOLUTEGRAVIR/RILPIVIRINE |
| DOSAGE FORM |
TAB |
| FORMULARY DESIGNATOR |
PA-F |
| FORMULARY DESIGNATOR TEXT |
Restricted to HIV/ID (or facility designated/authorized provider)
|
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| SINGLE/MULTI SOURCE PRODUCT |
Multisource |
| NATIONAL FORMULARY NAME |
DOLUTEGRAVIR/RILPIVIRINE TAB |
| 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: 2018-01-01 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
DOLUTEGRAVIR 50MG/RILPIVIRINE 25MG TAB |
| VA PRODUCT IDENTIFIER |
D1173 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
TAB |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4037155 |
| EFFECTIVE DATE/TIME |
-
- 2017-12-07 00:00:00
- STATUS: ACTIVE
|
