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 TRIAZ PAD 3% Brand‐O TIER 03 PATRIAZ PAD 6% Brand‐O TIER 03 PATRIAZ PAD 9% Brand‐O TIER 03 PATRIAZ CLEANS LOT 3% Brand‐O TIER 03 PATRIAZ CLEANS LOT 6% Brand‐O TIER 03 PATRIAZ CLEANS LOT 9% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 3% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 6% Brand‐O TIER 03 PATRIAZ CLOTHS MIS 9% Brand‐O TIER 03 PAUNIVERSAL GEL WATER BRAND TIER 03VAGINAL PREP KIT PACK BRAND TIER 03VAGINAL PREP KIT TRAY BRAND TIER 03WINGED GRIP MIS SPONGE BRAND TIER 03ZACARE KIT KIT 4% BRAND TIER 03ZACARE KIT KIT 8% BRAND TIER 03ZACLIR LOT 4% GENERIC TIER 01ZACLIR LOT 8% GENERIC TIER 01BENZEFOAM AER 5.3% Brand‐O TIER 99 PA DEIODINE TIN 2% GENERIC TIER 01HYDROGEN PER SOL 30% GENERIC TIER 01POT PERMANGT GRA GENERIC TIER 99 DEBENZOYL PER GEL 5% GENERIC TIER 01LOOP DIURETICS BUMETANIDE INJ 0.25/ML GENERIC TIER 01BUMETANIDE TAB 0.5MG GENERIC TIER 01BUMETANIDE TAB 1MG GENERIC TIER 01BUMETANIDE TAB 2MG GENERIC TIER 01DEMADEX TAB 100MG Brand‐O TIER 03 PADEMADEX TAB 10MG Brand‐O TIER 03 PADEMADEX TAB 20MG Brand‐O TIER 03 PADEMADEX TAB 5MG Brand‐O TIER 03 PAEDECRIN TAB 25MG BRAND TIER 03FUROSEMIDE INJ 10MG/ML GENERIC TIER 01FUROSEMIDE SOL 10MG/ML GENERIC TIER 01FUROSEMIDE SOL 8MG/ML GENERIC TIER 01FUROSEMIDE TAB 20MG GENERIC TIER 01FUROSEMIDE TAB 40MG GENERIC TIER 01FUROSEMIDE TAB 80MG GENERIC TIER 01LASIX TAB 20MG Brand‐O TIER 03 PALASIX TAB 40MG Brand‐O TIER 03 PAKey: 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= DrugExclusion176