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. VANIQA CRE 13.9% BRAND TIER 03VASOLEX OIN GENERIC TIER 99 DEVECTICAL OIN 3MCG/GM BRAND TIER 02VELTIN GEL BRAND TIER 02 PAVENELEX OIN BRAND TIER 03VEREGEN OIN 15% BRAND TIER 03VOLTAREN GEL 1% BRAND TIER 03 PA QLXCLAIR CRE GENERIC TIER 01ZIANA GEL BRAND TIER 03 PAZITHRANOL SHA 1% BRAND TIER 03ZITHRANOL‐RR CRE 1.2% BRAND TIER 03ZYCLARA CRE 3.75% BRAND TIER 03 PA QLZYCLARA PUMP CRE 2.5% BRAND TIER 03 PAZYCLARA PUMP CRE 3.75% BRAND TIER 03 PA QLGRANULEX AER Brand‐O TIER 99 PA DEXENADERM OIN Brand‐O TIER 99 PA DEGLYCOLIC ACD SOL 70% GENERIC TIER 01CARRASYN GEL DRESSING BRAND TIER 03PARAFFIN MIS GENERIC TIER 99 DESOMATOTROPIN AGONISTS EGRIFTA INJ 1MG BRAND TIER 03 PA QL SPEGRIFTA SOL 2MG BRAND TIER 03 PAGENOTROPIN INJ 0.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 0.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.2MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.4MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.6MG BRAND TIER 03 PA SPGENOTROPIN INJ 1.8MG BRAND TIER 03 PA SPGENOTROPIN INJ 12MG BRAND TIER 03 PA SPGENOTROPIN INJ 1MG BRAND TIER 03 PA SPGENOTROPIN INJ 2MG BRAND TIER 03 PA SPGENOTROPIN INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 12MG BRAND TIER 03 PA SPHUMATROPE INJ 24MG BRAND TIER 03 PA SPHUMATROPE INJ 5MG BRAND TIER 03 PA SPHUMATROPE INJ 6MG BRAND TIER 03 PA SPINCRELEX INJ 40MG/4ML BRAND TIER 03 PA SPNORDITROPIN INJ 10/1.5ML BRAND TIER 02 PA SPKey: 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= DrugExclusion260