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 (SKIN & MUCOUS MEMBRANE) METRONIDAZOL LOT 0.75% GENERIC TIER 01MEXAR WASH LIQ 10% GENERIC TIER 01MUPIROCIN OIN 2% GENERIC TIER 01 PANEO/POLY GU SOL 40/ML IR GENERIC TIER 01NEOSPORIN GU SOL 40/ML IR Brand‐O TIER 03 PANORITATE CRE 1% BRAND TIER 03OVACE PLUS CRE 10% BRAND TIER 02OVACE PLUS GEL 10% WASH BRAND TIER 03OVACE PLUS SHA 10% BRAND TIER 02OVACE WASH LIQ 10% Brand‐O TIER 03 PAROSADAN CRE 0.75% GENERIC TIER 01ROSADAN GEL 0.75% GENERIC TIER 01ROSADAN KIT 0.75% BRAND TIER 03SEB‐PREV LIQ WASH GENERIC TIER 01SEB‐PREV LOT 10% GENERIC TIER 01SOD SULFACET PAD 10% GENERIC TIER 01SODIUM SULFA LIQ 10% WASH GENERIC TIER 01SULFACETAMID LOT 10% GENERIC TIER 01SULFACETAMID SUS 10% GENERIC TIER 01VANDAZOLE GEL 0.75% GENERIC TIER 01VITAZOL CRE 0.75% GENERIC TIER 01ANTICHOLINERGIC AGENTS (CNS) BENZTROPINE INJ 1MG/ML GENERIC TIER 01BENZTROPINE TAB 0.5MG GENERIC TIER 01BENZTROPINE TAB 2MG GENERIC TIER 01COGENTIN INJ 1MG/ML Brand‐O TIER 03 PATRIHEXYPHEN ELX 0.4MG/ML GENERIC TIER 01TRIHEXYPHEN TAB 2MG GENERIC TIER 01TRIHEXYPHEN TAB 5MG GENERIC TIER 01ANTICOAGULANTS, MISCELLANEOUS ACD FORMULA SOL A GENERIC TIER 01ACD FORMULA SOL B GENERIC TIER 01ACD‐A SOL BRAND TIER 03ANTICOAG CPD SOL BRAND TIER 03ANTICOAGULNT SOL SOD CITR GENERIC TIER 01ATRYN INJ 1750 BRAND TIER 03CEPROTIN INJ 1000UNIT BRAND TIER 03CEPROTIN INJ 500 UNIT BRAND TIER 03NOCLOT‐50 SOL ACD‐A GENERIC TIER 01THROMBAT III INJ 1000UNIT BRAND TIER 03THROMBAT III INJ 500UNIT 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= DrugExclusion24