FOLLICLE STIMULATING 150UNT/LUTEINIZING HORMONE 150UNT/VIL INJ (7576)    VA PRODUCT (50.68)

Name Value
NAME FOLLICLE STIMULATING 150UNT/LUTEINIZING HORMONE 150UNT/VIL INJ
VA GENERIC NAME FOLLICLE STIMULATING HORMONE/LUTEINIZING HORMONE
DOSAGE FORM INJ,SOLN
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
INACTIVATION DATE 2009-11-17 00:00:00
DSS NUMBER 4
NATIONAL FORMULARY NAME FOLLICLE STIMULATING HORMONE/LUTEINIZING HORMONE INJ,SOLN
CREATE DEFAULT POSSIBLE DOSAGE YES
CODING SYSTEM
  • RxNorm
    CODE:
COPAY TIER
  • COPAY TIER LEVEL:   2
    COPAY EFFECTIVE DATE:   2017-02-27 00:00:00
PGX ELIGIBLE NO
PGX SUPPRESSED NO
VA PRINT NAME MENOTROPINSH 150/LH 150 UNT/VIL INJ
VA PRODUCT IDENTIFIER M0302
TRANSMIT TO CMOP NO
VA DISPENSE UNIT VI
MASTER ENTRY FOR VUID YES
VUID 4008076
EFFECTIVE DATE/TIME
  • 2005-03-10 00:00:00
    STATUS:   ACTIVE
  • 2009-11-17 00:00:00
    STATUS:   INACTIVE