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 UMECTA EMU BRAND TIER 03UMECTA SUS 40% Brand‐O TIER 03 PAUMECTA MOUSS AER 40% GENERIC TIER 01UMECTA NAIL SUS FILM Brand‐O TIER 03 PAUMECTA PD EMU 40‐0.3% BRAND TIER 03UMECTA PD SUS 40‐0.3% BRAND TIER 03URAMAXIN AER 20% GENERIC TIER 01URAMAXIN CRE 45% Brand‐O TIER 03 PAURAMAXIN GEL 45% Brand‐O TIER 03 PAURAMAXIN LOT 45% Brand‐O TIER 03 PAURAMAXIN GT KIT 45% BRAND TIER 03URAMAXIN GT SOL 45% Brand‐O TIER 03 PAUREA CRE 39% GENERIC TIER 01UREA CRE 40% GENERIC TIER 01UREA CRE 45% GENERIC TIER 01UREA CRE 50% GENERIC TIER 01UREA EMU 50% GENERIC TIER 01UREA GEL 40% GENERIC TIER 01UREA LOT 40% GENERIC TIER 01UREA LOT 45% GENERIC TIER 01UREA OIN 50% GENERIC TIER 01UREA SUS 50% GENERIC TIER 01UREA 40% SUS NAIL GENERIC TIER 01UREA HYDRATI AER 35% GENERIC TIER 01UREA NAIL GEL 45% GENERIC TIER 01UREA NAIL KIT GENERIC TIER 01UREA NAIL MIS 50% BRAND TIER 03UREA TOPICAL SUS 40% GENERIC TIER 01UREA‐C40 LOT 40% GENERIC TIER 01VIRASAL LIQ 27.5% Brand‐O TIER 03 PAVIRTI‐SULF CRE 10‐5% GENERIC TIER 01X‐VIATE CRE 40% GENERIC TIER 01X‐VIATE GEL 40% GENERIC TIER 01X‐VIATE LOT 40% GENERIC TIER 01ZENCIA LIQ 9‐4% GENERIC TIER 01KERATOPLASTIC AGENTS COAL TAR OIN 1% GENERIC TIER 01COAL TAR SOL 20% GENERIC TIER 01KETOLIDES KETEK TAB 300MG BRAND TIER 03KETEK TAB 400MG BRAND TIER 03Key: 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= DrugExclusion168