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 StatusANTIPRURITICS AND LOCAL ANESTHETICS LIDOCAINE OIN 5% GENERIC TIER 01LIDOCAINE SOL 4% GENERIC TIER 01LIDOCAINE/HC CRE 3%‐0.5% GENERIC TIER 01LIDOCAINE/HC KIT 2‐2% GENERIC TIER 01LIDOCAINE/HC KIT 3%‐0.5% GENERIC TIER 01LIDOCAINE/HC KIT 3%‐1% GENERIC TIER 01LIDOCAINE/HC KIT 3‐2.5% GENERIC TIER 01LIDODERM DIS 5% BRAND TIER 02LIDO‐HYDRO GEL 2.8‐0.55 GENERIC TIER 01PAIN EASE AER MD STRM BRAND TIER 03PAIN EASE AER MIST BRAND TIER 03PHENAZO TAB 200MG GENERIC TIER 01PHENAZOPYRID TAB 100MG GENERIC TIER 01PHENAZOPYRID TAB 200MG GENERIC TIER 01PHENAZOPYRID TAB PLUS GENERIC TIER 99 DEPONTOCAINE SOL 2% BRAND TIER 03PRAM‐HCA KIT 2.35‐1% GENERIC TIER 99 DEPRAMOX GEL 1% GENERIC TIER 01PROCORT CRE BRAND TIER 03PROCTOFOAM AER HC 1% BRAND TIER 02PRUDOXIN CRE 5% GENERIC TIER 01PYRIDIUM TAB 100MG Brand‐O TIER 03 PAPYRIDIUM TAB 200MG Brand‐O TIER 03 PAREGENECARE GEL BRAND TIER 03SYNERA DIS 70‐70MG BRAND TIER 03TOPEX TOPCAL SPR ANESTHET GENERIC TIER 01URELIEF PLUS TAB GENERIC TIER 99 DEXYLOCAINE GEL 2% Brand‐O TIER 03 PAXYLOCAINE SOL 4% Brand‐O TIER 03 PAZONALON CRE 5% BRAND TIER 03Z‐PRAM KIT 2.35‐1% GENERIC TIER 99 DEZYPRAM CRE 2.35‐1% BRAND TIER 03ANALPRAM‐HC CRE 1‐2.5% Brand‐O TIER 99 PA DEANALPRAM E KIT Brand‐O TIER 99 PA DEBENZYL ALC LIQ GENERIC TIER 99 DECAMPHOR GRA GENERIC TIER 99 DECAMPHOR CRY SYNTHET GENERIC TIER 99 DECAMPHOR CRY GENERIC TIER 99 DEANTIPSYCHOTICS, MISCELLANEOUS LOXAPINE CAP 10MG 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= DrugExclusion52