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 StatusLOCAL ANTI‐INFECTIVES, MISCELLANEOUS NEOBENZ MICR CRE 5.5% BRAND TIER 03NEOBENZ MICR CRE 8.5% BRAND TIER 03NEOBENZ MICR KIT PLUS PK Brand‐O TIER 03 PANEOBENZ MICR LIQ 7% WASH Brand‐O TIER 03 PAOSCION CLNSR LOT 6% GENERIC TIER 01OSCION CLNSR LOT 9% GENERIC TIER 01PACNEX HP PAD 7% BRAND TIER 03PACNEX LP PAD 4.25% BRAND TIER 03PACNEX MX LIQ 4.25% Brand‐O TIER 03 PAPACNEX WASH LIQ 7% GENERIC TIER 01PHENOL CRY GENERIC TIER 99 DEPHENOL LIQ GENERIC TIER 99 DEPHENOL LIQ 89% GENERIC TIER 99 DEPHISOHEX LIQ 3% BRAND TIER 03PR BENZOYL LIQ 7% WASH GENERIC TIER 01RA RENEWAL GEL 10% GENERIC TIER 01RELAGARD GEL BRAND TIER 03SE BPO 7‐5.5 KIT WASH KIT GENERIC TIER 01SE BPO CLOTH MIS 3% GENERIC TIER 01SE BPO CLOTH MIS 6% GENERIC TIER 01SE BPO CLOTH MIS 9% GENERIC TIER 01SE BPO WASH LIQ 7% GENERIC TIER 01SELENIUM SUL LOT 2.5% GENERIC TIER 01SELENIUM SUL SHA 2.25% GENERIC TIER 01SELENIUM SUL SHA 2.5% GENERIC TIER 01SELSUN SHA 2.5% Brand‐O TIER 03 PASILVADENE CRE 1% Brand‐O TIER 03 PASILVER SULFA CRE 1% GENERIC TIER 01SKIN SCRUB KIT PACK BRAND TIER 03SKIN SCRUB KIT PACK WET BRAND TIER 03SKIN SCRUB KIT TRAY WET BRAND TIER 03SOD HYPOCHLR SOL 5% GENERIC TIER 01SSD CRE 1% GENERIC TIER 01SSD AF CRE 1% GENERIC TIER 01SULFAMYLON CRE 85MG/GM BRAND TIER 03SULFAMYLON PAK 5% BRAND TIER 03TERSI FOAM AER 2.25% BRAND TIER 03THERMAZENE CRE 1% GENERIC TIER 01TL BPO MX LIQ 4.25% 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= DrugExclusion175