$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
FLUORIDE PRODUCTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
FLURA-TAB (sodium fluoride) |
|
$ |
|
ethedent (sodium fluoride) |
chew tab |
$ |
|
fluor-a-day (sodium fluoride) |
chew tab |
$ |
|
FLUORABON (sodium fluoride) |
|
$ |
|
FLUORITAB (sodium fluoride) |
|
$ |
|
FLURA-DROPS (sodium fluoride) |
|
$ |
|
LURIDE (sodium fluoride) |
|
$ |
|
sodium fluoride (sodium fluoride) |
0.25 mg chew tab |
$ |
|
sodium fluoride (sodium fluoride) |
0.5 mg chew tab |
$ |
|
sodium fluoride (sodium fluoride) |
1 mg chew tab |
$ |
|
sodium fluoride (sodium fluoride) |
oral drops |
$ |
|
sodium fluoride (sodium fluoride) |
tab |
Non-Formulary |
|
CAVAREST |
|
Non-Formulary |
|
CAVIRINSE |
|
Non-Formulary |
|
CONTROL RX |
|
Non-Formulary |
|
DENTA 5000 PLUS |
|
Non-Formulary |
|
DENTAGEL |
|
Non-Formulary |
|
EASYGEL |
|
Non-Formulary |
|
ETHEDENT |
|
Non-Formulary |
|
FLUOR-A-DAY |
|
Non-Formulary |
|
FLUORIDEX DAILY DEFENSE |
|
Non-Formulary |
|
FLUORIDEX SENSITIVITY RELIEF |
|
Non-Formulary |
|
FLURA |
|
Non-Formulary |
|
GEL-KAM |
|
Non-Formulary |
|
NEUTRAGARD ADVANCED |
|
Non-Formulary |
|
PERIO MED |
|
Non-Formulary |
|
PHOS-FLUR |
|
Non-Formulary |
|
PREVIDENT |
|
Non-Formulary |
|
PREVIDENT 5000 |
|
Non-Formulary |
|
PREVIDENT 5000 PLUS |
|
Non-Formulary |
|
PREVIDENT 5000 SENSITIVE |
|
Non-Formulary |
|
SF |
|
Non-Formulary |
|
SF 5000 PLUS |
|
Non-Formulary |
|
SODIUM FLUORIDE |
|
Non-Formulary |
|
STANIMAX |
|
Non-Formulary |
|
STANNOUS FLUORIDE |
|
Non-Formulary |
|
THERA-FLUR-N |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0