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 StatusANTIBACTERIALS (EENT) ILOTYCIN OIN OP GENERIC TIER 01IQUIX SOL 1.5% BRAND TIER 03 PALEVOFLOXACIN SOL 0.5% GENERIC TIER 01 PAMITOSOL KIT 0.2MG BRAND TIER 03MOXEZA SOL 0.5% BRAND TIER 02 PANEO/BAC/POLY OIN OP GENERIC TIER 01NEO/POLY/GRA SOL OP GENERIC TIER 01NEO‐POLYCIN OIN OP GENERIC TIER 01NEOSPORIN SOL OP Brand‐O TIER 03 PAOCUFLOX DRO 0.3% OP Brand‐O TIER 03 PAOFLOXACIN DRO 0.3% OP GENERIC TIER 01OFLOXACIN DRO 0.3%OTIC GENERIC TIER 01POLYCIN B OIN OP GENERIC TIER 01POLYMYXIN B/ SOL TRIMETHP GENERIC TIER 01POLYTRIM SOL OP Brand‐O TIER 03 PAQUIXIN SOL 0.5% Brand‐O TIER 03 PAROMYCIN OIN OP GENERIC TIER 01SOD SULFACET SOL 10% OP GENERIC TIER 01SULFACET SOD OIN 10% OP GENERIC TIER 01SULFACET SOD SOL 10% OP GENERIC TIER 01TOBRAMYCIN SOL 0.3% OP GENERIC TIER 01TOBRASOL SOL 0.3% OP GENERIC TIER 01TOBREX OIN 0.3% OP BRAND TIER 02TOBREX SOL 0.3% OP Brand‐O TIER 03 PATRIMETHOPRIM SOL POLYMYXN GENERIC TIER 01VIGAMOX DRO 0.5% BRAND TIER 02 PAZYMAXID SOL 0.5% BRAND TIER 02 PAANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) ACANYA GEL 1.2‐2.5% BRAND TIER 02 PAAKNE‐MYCIN OIN 2% BRAND TIER 03ALTABAX OIN 1% BRAND TIER 03 PABACTROBAN CRE 2% BRAND TIER 03 PABACTROBAN OIN 2% Brand‐O TIER 03 PABACTROBAN OIN NASAL 2% BRAND TIER 03BENZACLIN GEL 1‐5% Brand‐O TIER 03 PABENZACLIN GEL 1‐5%PUMP Brand‐O TIER 03 PABENZAMYCIN GEL Brand‐O TIER 03 PABENZAMYCIN GEL PAK BRAND TIER 03 PACENTANY OIN 2% GENERIC TIER 01 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= DrugExclusion22