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 StatusKERATOLYTIC AGENTS SALICYLIC CRY ACID GENERIC TIER 99 DESALICYLIC AC AER 6% GENERIC TIER 01SALICYLIC AC CRE 6% GENERIC TIER 01SALICYLIC AC GEL 6% GENERIC TIER 01SALICYLIC AC KIT 6% GENERIC TIER 01SALICYLIC AC KIT 6% CREAM GENERIC TIER 01SALICYLIC AC KIT 6% LOTN GENERIC TIER 01SALICYLIC AC LIQ 26% GENERIC TIER 01SALICYLIC AC LIQ 27.5% GENERIC TIER 01SALICYLIC AC LOT 6% GENERIC TIER 01SALICYLIC AC SHA 6% GENERIC TIER 01SALKERA AER 6% BRAND TIER 03SALVAX AER 6% Brand‐O TIER 03 PASALVAX AER 6% GENERIC TIER 01SALVAX DUO KIT PLUS BRAND TIER 03SE 10‐5 SS CRE 10‐5% GENERIC TIER 01SOD SUL/SULF AER 10‐5% GENERIC TIER 01SOD SUL/SULF CRE 10‐5% GENERIC TIER 01SOD SUL/SULF EMU 10‐5% GENERIC TIER 01SOD SUL/SULF GEL 10‐5% GENERIC TIER 01SOD SUL/SULF LIQ 9‐4.5% GENERIC TIER 01SOD SUL/SULF LIQ WASH GENERIC TIER 01SOD SUL/SULF LOT 10‐5% GENERIC TIER 01SOD SUL/SULF PAD 10‐4% GENERIC TIER 01SOD SUL/SULF PAD 10‐5% GENERIC TIER 01SOD SUL/SULF SUS 10‐5% GENERIC TIER 01SOD SUL/SULF SUS 8‐4% GENERIC TIER 01SSS 10‐4 AER 10‐4% BRAND TIER 03SULFACLEANSE SUS 8‐4% GENERIC TIER 01SULFOAM SHA 2% BRAND TIER 03SUMADAN KIT BRAND TIER 03SUMADAN WASH LIQ 9‐4.5% Brand‐O TIER 03 PASUMAXIN PAD 10‐4% Brand‐O TIER 03 PASUMAXIN CP KIT BRAND TIER 03SUMAXIN TS SUS 8‐4% Brand‐O TIER 03 PASUMAXIN WASH LIQ 9‐4% Brand‐O TIER 03 PASUPHERA CRE 10‐5% GENERIC TIER 01TL UREA LOT 45% GENERIC TIER 01U‐KERA E CRE 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= DrugExclusion167