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 (SKIN & MUCOUS) CAPEX SHA 0.01% BRAND TIER 02 PACARMOL‐HC CRE 1% Brand‐O TIER 03 PACLOBETA KIT CREAM BRAND TIER 03CLOBETA KIT OINTMENT BRAND TIER 03CLOBETASOL AER 0.05% GENERIC TIER 01CLOBETASOL CRE 0.05% GENERIC TIER 01CLOBETASOL GEL 0.05% GENERIC TIER 01CLOBETASOL LOT 0.05% GENERIC TIER 01 PACLOBETASOL OIN 0.05% GENERIC TIER 01CLOBETASOL SHA 0.05% GENERIC TIER 01 PACLOBETASOL SOL 0.05% GENERIC TIER 01CLOBETASOL E CRE 0.05% GENERIC TIER 01CLOBEX LOT 0.05% Brand‐O TIER 02 PACLOBEX SHA 0.05% Brand‐O TIER 02 PACLOBEX SPR 0.05% BRAND TIER 02 PACLODERM CRE 0.1% BRAND TIER 03CLODERM CRE 0.1% PMP BRAND TIER 03COLOCORT ENE 100MG GENERIC TIER 01CORDRAN LOT 0.05% BRAND TIER 03CORDRAN 24X3 TAP 4MCG/CM BRAND TIER 02CORDRAN 80X3 TAP 4MCG/CM BRAND TIER 02CORDRAN SP CRE 0.05% BRAND TIER 03CORMAX OIN 0.05% GENERIC TIER 01CORMAX SOL 0.05% GENERIC TIER 01CORMAX SCALP SOL 0.05% GENERIC TIER 01CORTALO GEL 2% GENERIC TIER 01CORTANE‐B LOT BRAND TIER 99 DECORTENEMA ENE 100MG Brand‐O TIER 03 PACORTIFOAM AER 90MG BRAND TIER 02CORTISPORIN CRE 0.5% BRAND TIER 03CORTISPORIN OIN 1% BRAND TIER 03CUTIVATE CRE 0.05% Brand‐O TIER 03 PACUTIVATE LOT 0.05% Brand‐O TIER 03 PACUTIVATE OIN 0.005% Brand‐O TIER 03 PADERMA‐SMOOTH OIL /FS BODY Brand‐O TIER 03 PADERMA‐SMOOTH OIL /FS SCLP Brand‐O TIER 03 PADERMATOP CRE 0.1% Brand‐O TIER 03 PADERMATOP OIN 0.1% Brand‐O TIER 03 PADESONATE GEL 0.05% 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= DrugExclusion34