| NAME |
PREVIDENT 5000 DRY MOUTH GEL,DENT |
| VA GENERIC NAME |
SODIUM FLUORIDE |
| DOSAGE FORM |
GEL |
| FORMULARY DESIGNATOR TEXT |
Not provided by pharmacy for inpatient use.
|
| ACTIVE INGREDIENTS |
|
| CS FEDERAL SCHEDULE |
Unscheduled |
| STRENGTH |
1.1 |
| SINGLE/MULTI SOURCE PRODUCT |
Multisource |
| UNITS |
% |
| NATIONAL FORMULARY NAME |
SODIUM FLUORIDE GEL |
| CREATE DEFAULT POSSIBLE DOSAGE |
YES |
| CODING SYSTEM |
|
| COPAY TIER |
-
- COPAY TIER LEVEL: 3
- COPAY EFFECTIVE DATE: 2017-07-01 00:00:00
- COPAY END DATE: 2022-03-02 00:00:00
-
- COPAY TIER LEVEL: 2
- COPAY EFFECTIVE DATE: 2022-03-03 00:00:00
|
| PGX ELIGIBLE |
NO |
| PGX SUPPRESSED |
NO |
| VA PRINT NAME |
PREVIDENT 5000 DRY MOUTH DENT GEL |
| VA PRODUCT IDENTIFIER |
P1192 |
| TRANSMIT TO CMOP |
YES |
| VA DISPENSE UNIT |
GM |
| MASTER ENTRY FOR VUID |
YES |
| VUID |
4036723 |
| EFFECTIVE DATE/TIME |
-
- 2017-06-02 00:00:00
- STATUS: ACTIVE
|
