BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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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. PICATO GEL 0.015% BRAND TIER 02PICATO GEL 0.05% BRAND TIER 02PODOCON SOL 25% GENERIC TIER 01PODOFILOX SOL 0.5% GENERIC TIER 01 PAPR CREAM KIT BRAND TIER 03PROPECIA TAB 1MG BRAND TIER 99 DEPROTOPIC OIN 0.03% BRAND TIER 02 PA QLPROTOPIC OIN 0.1% BRAND TIER 02 PA QLPRUTECT EMU GENERIC TIER 01QUTENZA KIT 8% 1‐PCH BRAND TIER 03 PA QLQUTENZA KIT 8% 2‐PCH BRAND TIER 03 PA QLRADIAGEL GEL GENERIC TIER 01RADIAPLEXRX GEL BRAND TIER 03RADIGEL GEL BRAND TIER 03RECTIV OIN 0.4% BRAND TIER 03REGRANEX GEL 0.01% BRAND TIER 03RESTORE SILV PAD 2"X2" BRAND TIER 03RESTORE SILV PAD 4"X4" BRAND TIER 03RESTORE SILV PAD 4"X4.75" BRAND TIER 03RESTORE SILV PAD 4"X5" BRAND TIER 03RESTORE SILV PAD 6"X8" BRAND TIER 03REVINA OIN GENERIC TIER 99 DESALICEPT SOL GENERIC TIER 01SALICEPT SUS BRAND TIER 03SANTYL OIN 250/GM BRAND TIER 02SILVASORB GEL BRAND TIER 03SILVRSTAT GEL DRESSING BRAND TIER 03SOLARAZE GEL 3% W/W BRAND TIER 03SOLODYN TAB 105MG BRAND TIER 03 PASOLODYN TAB 115MG BRAND TIER 03 PASOLODYN TAB 135MG Brand‐O TIER 03 PASOLODYN TAB 45MG Brand‐O TIER 03 PASOLODYN TAB 55MG BRAND TIER 03 PASOLODYN TAB 65MG BRAND TIER 03 PASOLODYN TAB 80MG BRAND TIER 03 PASOLODYN TAB 90MG Brand‐O TIER 03 PASONAFINE EMU GENERIC TIER 01SORIATANE CAP 10MG BRAND TIER 02SORIATANE CAP 17.5MG BRAND TIER 02Key: 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= DrugExclusion258
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. SORIATANE CAP 25MG BRAND TIER 02SORILUX AER 0.005% BRAND TIER 03SOTRET CAP 10MG GENERIC TIER 01SOTRET CAP 20MG GENERIC TIER 01SOTRET CAP 30MG GENERIC TIER 01SPECTRAGEL GEL BRAND TIER 03STELARA INJ 45MG/0.5 BRAND TIER 03 PA QL SPSTELARA INJ 90MG/ML BRAND TIER 03 PA QL SPSURGICEL PAD 0.5"X2" BRAND TIER 03SURGICEL PAD 1"X 1" BRAND TIER 03SURGICEL PAD 1"X2" BRAND TIER 03SURGICEL PAD 1"X3.5" BRAND TIER 03SURGICEL PAD 2"X14" BRAND TIER 03SURGICEL PAD 2"X3" BRAND TIER 03SURGICEL PAD 2"X4" BRAND TIER 03SURGICEL PAD 3"X4" BRAND TIER 03SURGICEL PAD 4"X4" BRAND TIER 03SURGICEL PAD 4"X8" BRAND TIER 03SURGICEL PAD 6"X9" BRAND TIER 03TACHOSIL PAD BRAND TIER 99 DETARGRETIN GEL 1% BRAND TIER 03 SPTAZORAC CRE 0.05% BRAND TIER 02 PATAZORAC CRE 0.1% BRAND TIER 02 PATAZORAC GEL 0.05% BRAND TIER 02 PATAZORAC GEL 0.1% BRAND TIER 02 PATBC AER GENERIC TIER 99 DETEGADERM AG PAD 2"X2" BRAND TIER 03TEGADERM AG PAD 4"X5" BRAND TIER 03TEGADERM AG PAD 4"X8" BRAND TIER 03TEGADERM AG PAD 8"X8" BRAND TIER 03TETRIX KIT BRAND TIER 03TISSEEL KIT BRAND TIER 03TISSEEL SOL BRAND TIER 03TL‐CERMIDE EMU BRAND TIER 03TROPAZONE CRE GENERIC TIER 01ULTEC PRO PAD 4"X4" BRAND TIER 03ULTEC PRO PAD 4"X5" BRAND TIER 03ULTEC PRO PAD 6"X6" BRAND TIER 03ULTEC PRO PAD 8"X8" 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= DrugExclusion259
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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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