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 StatusANTI‐INFLAMMATORY AGENTS (GI DRUGS) ASACOL TAB 400MG DR BRAND TIER 02ASACOL HD TAB 800MG BRAND TIER 02BALSALAZIDE CAP 750MG GENERIC TIER 01CANASA SUP 1000MG BRAND TIER 02COLAZAL CAP 750MG Brand‐O TIER 03 PADIPENTUM CAP 250MG BRAND TIER 03LIALDA TAB 1.2GM BRAND TIER 03LOTRONEX TAB 0.5MG BRAND TIER 02LOTRONEX TAB 1MG BRAND TIER 02MESALAMINE ENE 4GM GENERIC TIER 01MESALAMINE KIT 4GM GENERIC TIER 99 DEPENTASA CAP 250MG CR BRAND TIER 02PENTASA CAP 500MG CR BRAND TIER 02SFROWASA ENE 4GM BRAND TIER 03ROWASA KIT 4GM Brand‐O TIER 99 PA DEANTI‐INFLAMMATORY AGENTS (SKIN & MUCOUS) ACLOVATE CRE 0.05% Brand‐O TIER 03 PAALA SCALP LOT 2% Brand‐O TIER 03 PAALCLOMETASON CRE 0.05% GENERIC TIER 01ALCLOMETASON OIN 0.05% GENERIC TIER 01ALPHATREX GEL 0.05% GENERIC TIER 01AMCINONIDE CRE 0.1% GENERIC TIER 01AMCINONIDE LOT 0.1% GENERIC TIER 01AMCINONIDE OIN 0.1% GENERIC TIER 01ANUCORT‐HC SUP 25MG GENERIC TIER 99 DEANUSOL‐HC CRE 2.5% Brand‐O TIER 02 PAAPEXICON OIN 0.05% GENERIC TIER 01APEXICON E CRE 0.05% GENERIC TIER 01AQUA GLYC HC KIT SCLP/BDY BRAND TIER 03AUG BETAMET CRE 0.05% GENERIC TIER 01AUG BETAMET GEL 0.05% GENERIC TIER 01AUG BETAMET LOT 0.05% GENERIC TIER 01AUG BETAMET OIN 0.05% GENERIC TIER 01BETAMETH DIP CRE 0.05% GENERIC TIER 01BETAMETH DIP LOT 0.05% GENERIC TIER 01BETAMETH DIP OIN 0.05% GENERIC TIER 01BETAMETH VAL CRE 0.1% GENERIC TIER 01BETAMETH VAL LOT 0.1% GENERIC TIER 01BETAMETH VAL OIN 0.1% 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= DrugExclusion33