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 StatusLINCOMYCINS CLINDAMYCIN INJ 900/6ML GENERIC TIER 01 SPCLINDAMYCIN INJ 9000/60 GENERIC TIER 01 SPCLINDAMYCIN INJ 900MG GENERIC TIER 01 SPCLINDAMYCIN SOL 75MG/5ML GENERIC TIER 01LINCOCIN INJ 300MG/ML BRAND TIER 03LIPOTROPIC AGENTS CHOLINE BIT CRY FCC GENERIC TIER 99 DELECITHIN GRA GENERIC TIER 01LIPMAX SOL BRAND TIER 99 DEPCCA LECITHI SOL ISOPROPY BRAND TIER 99 DELOCAL ANESTHETICS (EENT) AKTEN GEL 3.5% BRAND TIER 99 DEALCAINE SOL 0.5% OP Brand‐O TIER 03 PAALTACAINE SOL 0.5% OP GENERIC TIER 01ANTIPY/BENZO DRO OTIC GENERIC TIER 01ANTIPY/BENZO SOL 14‐54MG GENERIC TIER 01ANTIPY/BENZO SOL OTIC GENERIC TIER 01AURALGAN SOL 1.4‐5.5% Brand‐O TIER 03 PAAURAX SOL 1.4‐5.5% GENERIC TIER 01AURODEX SOL OTIC GENERIC TIER 01COCAINE HCL SOL 10% GENERIC TIER 01COCAINE HCL SOL 4% GENERIC TIER 01LIDOCAINE SOL 2% VISC GENERIC TIER 01LTA 360 KIT SOL 4% Brand‐O TIER 03 PAMYOXIN SUS OTIC GENERIC TIER 01NEOTIC DRO Brand‐O TIER 03 PAOTIC CARE DRO GENERIC TIER 01OTICIN DRO 1‐0.1% GENERIC TIER 01OTOZIN DRO GENERIC TIER 01PARCAINE SOL 0.5% OP GENERIC TIER 01PINNACAINE DRO 20% OTIC BRAND TIER 03PRAMOTIC DRO 1‐0.1% Brand‐O TIER 03 PAPROPARACAINE SOL 0.5% OP GENERIC TIER 01TETCAINE SOL 0.5% OP GENERIC TIER 01TETRACAINE SOL 0.5% OP GENERIC TIER 01TETRAVISC SOL 0.5% OP GENERIC TIER 01TETRAVISC SOL FORTE GENERIC TIER 01TREAGAN OTIC DRO Brand‐O TIER 03 PATRIOXIN SUS OTIC Brand‐O TIER 03 PAZINOTIC DRO BRAND TIER 03ZINOTIC ES DRO 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= DrugExclusion170