BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusDEPIGMENTING AGENTS ACLARO PD EMU 4% BRAND TIER 99 DEALPHAQUIN HP CRE 4% GENERIC TIER 01ELDOPAQUE CRE 4% FORTE Brand‐O TIER 03 PAELDOQUIN CRE 4% FORTE Brand‐O TIER 03 PAEPIQUIN MICR CRE 4% Brand‐O TIER 03 PAEPIQUIN MICR CRE 4% PUMP Brand‐O TIER 03 PAHYDROQUINONE CRE 4% GENERIC TIER 01HYDROQUINONE CRE 4% TR GENERIC TIER 01HYDROQUINONE CRE 4%/SUNS GENERIC TIER 01HYDROQUINONE EMU 4% GENERIC TIER 99 DEHYDROQUINONE GEL 4%/SUNS GENERIC TIER 01LUSTRA CRE 4% Brand‐O TIER 03 PALUSTRA‐AF CRE 4% Brand‐O TIER 03 PALUSTRA‐ULTRA CRE 4% Brand‐O TIER 03 PAMELPAQUE HP CRE 4% GENERIC TIER 01MELQUIN 3 SOL 3% GENERIC TIER 01MELQUIN HP CRE 4% GENERIC TIER 01NAVA‐SC CRE 4% GENERIC TIER 01NUQUIN HP CRE 4% GENERIC TIER 01NUQUIN HP GEL 4% GENERIC TIER 01REMERGENT HQ CRE 4% GENERIC TIER 01SKIN BLEACH CRE 4% GENERIC TIER 01SKIN BLEACH CRE SUNSCREE GENERIC TIER 01TL HYDROQUIN CRE 4% GENERIC TIER 01TRI‐LUMA CRE BRAND TIER 03DEVICES 1 ML SYRIMGE MIS 18GX1" BRAND TIER 0310ML SYRINGE MIS 20GX1" BRAND TIER 0310ML SYRINGE MIS 20GX1.5" BRAND TIER 0310ML SYRINGE MIS 21GX1.5" BRAND TIER 0310ML SYRINGE MIS 22GX1.5" BRAND TIER 0312ML SYRINGE MIS /SHIELD BRAND TIER 0312ML SYRINGE MIS CANNULA BRAND TIER 0312ML SYRINGE MIS ECC LUER BRAND TIER 0312ML SYRINGE MIS LUER LOK BRAND TIER 031ML SYRINGE MIS 25GX1" BRAND TIER 031ML SYRINGE MIS 27GX1/2" BRAND TIER 031ML TB SYRNG MIS /LUER BRAND TIER 031ML TB SYRNG MIS LUER LOK BRAND TIER 031ML TB SYRNG MIS LUER SLP GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion101