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 StatusAZOLES (SKIN & MUCOUS MEMBRANE) KETOCONAZOLE AER 2% GENERIC TIER 01 PAKETOCONAZOLE CRE 2% GENERIC TIER 01KETOCONAZOLE SHA 2% GENERIC TIER 01KETODAN AER 2% GENERIC TIER 01 PAKETODAN KIT 2% BRAND TIER 03LOTRISONE CRE Brand‐O TIER 03 PAMICONAZOLE 3 KIT COMBO PK GENERIC TIER 01MICONAZOLE 3 SUP 200MG GENERIC TIER 01NIZORAL SHA 2% Brand‐O TIER 03 PANUZOLE CRE 2% GENERIC TIER 01ORAVIG TAB 50MG BRAND TIER 03 QLOXISTAT CRE 1% BRAND TIER 03OXISTAT LOT 1% BRAND TIER 03TERAZOL 3 CRE 0.8% Brand‐O TIER 03 PATERAZOL 3 SUP 80MG Brand‐O TIER 03 PATERAZOL 7 CRE 0.4% Brand‐O TIER 03 PATERCONAZOLE CRE 0.4% GENERIC TIER 01TERCONAZOLE CRE 0.8% GENERIC TIER 01TERCONAZOLE SUP 80MG GENERIC TIER 01VUSION OIN BRAND TIER 03XOLEGEL GEL 2% BRAND TIER 03XOLEGEL KIT COREPAK BRAND TIER 99 DEXOLEGEL DUO/ KIT HEAD&SHD BRAND TIER 99 DEXOLEGEL DUO/ KIT XOLEX BRAND TIER 99 DEZAZOLE CRE 0.4% GENERIC TIER 01ZAZOLE CRE 0.8% GENERIC TIER 01ZAZOLE SUP 80MG GENERIC TIER 01CLOTRIMAZOLE CRE 1% GENERIC TIER 01BACITRACINS BACIIM INJ 50000UNT GENERIC TIER 01BACITRACIN INJ 50000UNT GENERIC TIER 01BARBITURATES (ANTICONVULSANTS) MYSOLINE TAB 250MG Brand‐O TIER 03 PAMYSOLINE TAB 50MG Brand‐O TIER 03 PAPRIMIDONE TAB 250MG GENERIC TIER 01PRIMIDONE TAB 50MG GENERIC TIER 01BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) AMYTAL SOD INJ 500MG BRAND TIER 03BUTISOL SOD ELX 30MG/5ML BRAND TIER 03BUTISOL SOD TAB 30MG BRAND TIER 03BUTISOL SOD TAB 50MG BRAND TIER 03LUMINAL INJ 130MG/ML Brand‐O TIER 03 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= DrugExclusion65