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. FLUOROURACIL SOL 5% GENERIC TIER 01GELCLAIR GEL BRAND TIER 03GENADUR LIQ BRAND TIER 03HYDROFERA PAD 4"X4" BRAND TIER 03HYLASE WOUND GEL BRAND TIER 03IMIQUIMOD CRE 5% GENERIC TIER 01 PA QLINTERCED TC7 PAD 1.5"X2" BRAND TIER 03INTERCED TC7 PAD 3"X4" BRAND TIER 03LATISSE SOL 0.03% BRAND TIER 99 DELEVULAN KERA SOL 20% BRAND TIER 03MEDIHONEY PAD 2"X2" BRAND TIER 03MEDIHONEY PAD 4"X5" BRAND TIER 03METVIXIA CRE 16.8% BRAND TIER 03MINOCYCLINE TAB 135MG ER GENERIC TIER 01 PAMINOCYCLINE TAB 45MG ER GENERIC TIER 01 PAMINOCYCLINE TAB 90MG ER GENERIC TIER 01 PAMUCOTROL WAF BRAND TIER 03MUGARD LIQ BRAND TIER 03MYORISAN CAP 10MG GENERIC TIER 01MYORISAN CAP 20MG GENERIC TIER 01MYORISAN CAP 40MG GENERIC TIER 01NUOX GEL 6‐3% BRAND TIER 03NUVAIL SOL 16% BRAND TIER 99 DEOASIS BURN MIS 7X20CM BRAND TIER 03OASIS ULTRA MIS TRI MESH BRAND TIER 03OASIS WOUND MIS 3X3.5CM BRAND TIER 03OASIS WOUND MIS 3X7CM BRAND TIER 03OASIS WOUND MIS 7X10CM BRAND TIER 03OASIS WOUND MIS 7X20CM BRAND TIER 03OPTASE GEL BRAND TIER 99 DEORACEA CAP 40MG BRAND TIER 02 PAORAMAGICRX SUS BRAND TIER 03OXYCEL COTTN PAD 2"X1"X1" BRAND TIER 03OXYCEL GAUZE PAD 18"X2" BRAND TIER 03OXYCEL GAUZE PAD 3"X3" BRAND TIER 03OXYCEL GAUZE PAD 36"X1/2" BRAND TIER 03OXYCEL GAUZE PAD 5"X1/2" BRAND TIER 03PANRETIN GEL 0.1% BRAND TIER 02PENNSAID SOL 1.5% BRAND TIER 03 PA QLKey: 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= DrugExclusion257