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) DESONIDE CRE 0.05% GENERIC TIER 01DESONIDE LOT 0.05% GENERIC TIER 01DESONIDE OIN 0.05% GENERIC TIER 01DESONIL KIT 0.05% BRAND TIER 03DESONIL PLUS KIT CREAM BRAND TIER 03DESONIL PLUS KIT OINTMENT BRAND TIER 03DESOWEN CRE 0.05% Brand‐O TIER 03 PADESOWEN LOT 0.05% Brand‐O TIER 03 PADESOWEN OIN 0.05% Brand‐O TIER 03 PADESOWEN CRM KIT 0.05% BRAND TIER 03DESOWEN LOT KIT 0.05% BRAND TIER 99 DEDESOWEN OINT KIT 0.05% BRAND TIER 03DESOXIMETAS CRE 0.05% GENERIC TIER 01DESOXIMETAS CRE 0.25% GENERIC TIER 01DESOXIMETAS GEL 0.05% GENERIC TIER 01DESOXIMETAS OIN 0.05% GENERIC TIER 01DESOXIMETAS OIN 0.25% GENERIC TIER 01DIFLORASONE CRE 0.05% GENERIC TIER 01DIFLORASONE OIN 0.05% GENERIC TIER 01DIPROLENE LOT 0.05% Brand‐O TIER 03 PADIPROLENE OIN 0.05% Brand‐O TIER 03 PADIPROLENE AF CRE 0.05% Brand‐O TIER 03 PAELOCON CRE 0.1% Brand‐O TIER 03 PAELOCON LOT 0.1% Brand‐O TIER 03 PAELOCON OIN 0.1% Brand‐O TIER 03 PAEPIFOAM AER 1% BRAND TIER 03FLUOCIN ACET CRE 0.01% GENERIC TIER 01 PAFLUOCIN ACET CRE 0.025% GENERIC TIER 01 PAFLUOCIN ACET OIL BODY GENERIC TIER 01 PAFLUOCIN ACET OIL SCALP GENERIC TIER 01 PAFLUOCIN ACET OIN 0.025% GENERIC TIER 01 PAFLUOCIN ACET SOL 0.01% GENERIC TIER 01 PAFLUOCINONIDE CRE 0.05% GENERIC TIER 01FLUOCINONIDE CRE ‐E 0.05% GENERIC TIER 01FLUOCINONIDE GEL 0.05% GENERIC TIER 01FLUOCINONIDE OIN 0.05% GENERIC TIER 01FLUOCINONIDE SOL 0.05% GENERIC TIER 01FLUTICASONE CRE 0.05% GENERIC TIER 01 PAFLUTICASONE LOT 0.05% GENERIC TIER 01 PAKey: 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= DrugExclusion35