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 StatusSKIN AND MUCOUS MEMBRANE AGENTS, MISC. CURASORB MIS 36" ROPE BRAND TIER 03CURASORB MIS 4"X4" BRAND TIER 03CURASORB MIS 4"X5.5" BRAND TIER 03CURASORB MIS 4"X8" BRAND TIER 03CURASORB MIS 6"X10" BRAND TIER 03CURASORB PLS MIS 4"X4" BRAND TIER 03CURASORB ZN MIS 12" ROPE BRAND TIER 03CURASORB ZN PAD 2"X2" BRAND TIER 03CURASORB ZN PAD 4"X4" BRAND TIER 03CURASORB ZN PAD 4"X8" BRAND TIER 03CURITY HYPER MIS 1/2"X15' BRAND TIER 03CURITY NACL PAD 6"X6‐3/4 BRAND TIER 03CURITY WET PAD 8"X4" BRAND TIER 03DIAB GEL GENERIC TIER 01DIAB F.D.G. GEL GENERIC TIER 01DIFFERIN CRE 0.1% Brand‐O TIER 02 PADIFFERIN GEL 0.1% Brand‐O TIER 02 PADIFFERIN GEL 0.3% BRAND TIER 02 PADIFFERIN LOT 0.1% BRAND TIER 02 PADOVONEX CRE 0.005% Brand‐O TIER 03 PADOVONX SCALP SOL 0.005% Brand‐O TIER 03 PADRITHO‐CREME CRE HP 1% GENERIC TIER 01DRITHO‐SCALP CRE 0.5% BRAND TIER 02EFUDEX CRE 5% Brand‐O TIER 03 PAELIDEL CRE 1% BRAND TIER 02 PA QLEMULSION SB EMU BRAND TIER 03EPICERAM EMU BRAND TIER 03EPIDUO GEL 0.1‐2.5% BRAND TIER 02 PAEPISIL LIQ BRAND TIER 03EVICEL KIT 2ML BRAND TIER 03EVICEL KIT 5ML BRAND TIER 03FINACEA GEL 15% BRAND TIER 02 PAFINACEA PLUS KIT BRAND TIER 99 DEFLECTOR DIS 1.3% BRAND TIER 03 PA QLFLUOROPLEX CRE 1% BRAND TIER 03FLUOROURACIL CRE 5% GENERIC TIER 01FLUOROURACIL DRO 2% GENERIC TIER 01FLUOROURACIL DRO 5% GENERIC TIER 01FLUOROURACIL SOL 2% 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= DrugExclusion256