| NAME |
GLECAPREVIR 50MG/PIBRENTASVIR 20MG TAB DAILY PACK |
| VA GENERIC NAME |
GLECAPREVIR/PIBRENTASVIR |
| DOSAGE FORM |
TAB |
| HAZARDOUS TO DISPOSE |
NO |
| FORMULARY DESIGNATOR |
PA-F |
| ACTIVE INGREDIENTS |
|
| NATIONAL FORMULARY INDICATOR |
YES |
| CS FEDERAL SCHEDULE |
Unscheduled |
| SINGLE/MULTI SOURCE PRODUCT |
Single source |
| NATIONAL FORMULARY NAME |
GLECAPREVIR/PIBRENTASVIR TAB |
| CREATE DEFAULT POSSIBLE DOSAGE |
NO |
| POSSIBLE DOSAGES TO CREATE |
No Possible Dosages |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 3
- COPAY EFFECTIVE DATE: 2022-03-23 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
MAVYRET 50MG/20MG TAB DAILY PACK |
| VA PRODUCT IDENTIFIER |
M1286 |
| TRANSMIT TO CMOP |
NO |
| VA DISPENSE UNIT |
PKG |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4041276 |
| EFFECTIVE DATE/TIME |
-
- 2022-03-23 00:00:00
- STATUS: ACTIVE
|
