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 StatusEENT DRUGS, MISCELLANEOUS EYLEA INJ 2/0.05ML BRAND TIER 03HEALON INJ 10MG/ML BRAND TIER 03HEALON GV INJ 14MG/ML BRAND TIER 03HEALON5 INJ 23MG/ML BRAND TIER 03INTROL SOL 75% BRAND TIER 03IOPIDINE SOL 0.5% OP Brand‐O TIER 03 PAIOPIDINE SOL 1% OP BRAND TIER 03LACRISERT MIS 5MG OP BRAND TIER 02LUCENTIS SOL 0.3MG BRAND TIER 02 SPLUCENTIS SOL 0.5MG BRAND TIER 02 SPMACUGEN INJ BRAND TIER 03 SPNEUTRASAL POW BRAND TIER 03NUMOISYN LIQ GENERIC TIER 01NUMOISYN LOZ Brand‐O TIER 03 PAOCUCOAT SOL 2% OP GENERIC TIER 01PROPYLENE GL SOL USP GENERIC TIER 01PROVISC INJ 1% BRAND TIER 03SHELLGEL SOL BRAND TIER 03VISCOAT SOL BRAND TIER 03VISUDYNE INJ 15MG BRAND TIER 03 SPVOSOL SOL 2% OTIC Brand‐O TIER 03 PAEENT NONSTEROIDAL ANTI‐INFLAM. AGENTS ACULAR SOL 0.5% OP Brand‐O TIER 03 PAACULAR LS SOL 0.4% Brand‐O TIER 03 PAACUVAIL SOL 0.45% BRAND TIER 03 PABROMDAY SOL 0.09% BRAND TIER 03 PABROMFENAC SOL 0.09% GENERIC TIER 01 PADICLOFENAC SOL 0.1% OP GENERIC TIER 01FLURBIPROFEN SOL 0.03% OP GENERIC TIER 01KETOROLAC SOL 0.4% GENERIC TIER 01 PAKETOROLAC SOL 0.5% GENERIC TIER 01 PANEVANAC SUS 0.1% BRAND TIER 02 PAOCUFEN SOL 0.03% OP Brand‐O TIER 03 PAVOLTAREN SOL 0.1% OP Brand‐O TIER 03 PAXIBROM SOL 0.09% Brand‐O TIER 03 PAEMOLLIENTS, DEMULCENTS, AND PROTECTANTS AURSTAT KIT BRAND TIER 03HYLATOPC PLS KIT /AURSTAT BRAND TIER 99 DEMB HYDROGEL KIT BRAND TIER 03HPR PLUS MB KIT HYDROGEL BRAND TIER 99 DEKey: 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= DrugExclusion138