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 StatusIRRIGATING SOLUTIONS DIANEAL PD‐2 SOL 2.5% DEX BRAND TIER 03DIANEAL PD‐2 SOL 4.25%DEX BRAND TIER 03EXTRANEAL SOL BRAND TIER 03GLYCINE SOL 1.5% IRR GENERIC TIER 01HYSKON SOL BRAND TIER 03INPERSOL/DEX SOL 1.5% GENERIC TIER 01INPERSOL/DEX SOL 2.5% GENERIC TIER 01INPERSOL/DEX SOL 4.25% GENERIC TIER 01INPERSOL‐LM/ SOL 1.5% DEX GENERIC TIER 01INPERSOL‐LM/ SOL 2.5% DEX GENERIC TIER 01INPERSOL‐LM/ SOL 4.25 DEX GENERIC TIER 01LACTATED RIN SOL IRRIGAT GENERIC TIER 01PHYSIOLYTE SOL GENERIC TIER 01PHYSIOSOL SOL IRRIGAT BRAND TIER 03PHYSIOSOL SOL IRRIGAT GENERIC TIER 01RENACIDIN SOL IRR BRAND TIER 03RESECTISOL SOL 5% BRAND TIER 03RINGERS IRR SOL GENERIC TIER 01SODIUM CHLOR SOL 0.9% IRR GENERIC TIER 01SORBITOL SOL 3% IRR GENERIC TIER 01SORBITOL SOL 3.3% IRR GENERIC TIER 01SORBITOL‐MAN SOL GENERIC TIER 01STERIL WATER SOL IRRIG GENERIC TIER 01TIS‐U‐SOL SOL GENERIC TIER 01ULTRABAG/ SOL DIANEAL BRAND TIER 03ULTRABAG/PD2 SOL DIANEAL BRAND TIER 03KERATOLYTIC AGENTS ALICLEN SHA 6% GENERIC TIER 01ALUVEA CRE 39% Brand‐O TIER 03 PAAVAR CLEANSE EMU 10‐5% GENERIC TIER 01AVAR LS LIQ 10‐2% BRAND TIER 03AVAR‐E EMOLL CRE 10‐5% GENERIC TIER 01AVAR‐E GREEN CRE 10‐5% GENERIC TIER 01AVAR‐E LS CRE 10‐2% BRAND TIER 03BP 10‐1 EMU GENERIC TIER 01BP CLEANSING EMU 10‐4% GENERIC TIER 01CEM‐UREA SOL 45% GENERIC TIER 01CERISA WASH EMU 10‐1% GENERIC TIER 01CEROVEL GEL 40% GENERIC TIER 01CEROVEL LOT 40% 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= DrugExclusion165