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 StatusCARIOSTATIC AGENTS DENTA 5000 CRE PLUS GENERIC TIER 01DENTA 5000 CRE PLUS 2PK GENERIC TIER 01DENTAGEL GEL 1.1% GENERIC TIER 01EASYGEL GEL 0.4% GENERIC TIER 01EASYGEL GEL 0.4%CHRY GENERIC TIER 01EASYGEL GEL 0.4%CITR GENERIC TIER 01EASYGEL GEL 0.4%MINT GENERIC TIER 01EPIFLUR CHW 0.25MG F GENERIC TIER 01EPIFLUR CHW 0.5MG F GENERIC TIER 01EPIFLUR CHW 1MG F GENERIC TIER 01FLUORABON DRO BRAND TIER 02FLUOR‐A‐DAY CHW 0.25MG F BRAND TIER 02FLUOR‐A‐DAY CHW 0.5MG F BRAND TIER 02FLUOR‐A‐DAY CHW 1MG F BRAND TIER 03FLUOR‐A‐DAY DRO 0.125MG GENERIC TIER 01FLUORIDE CHW 0.25MG F GENERIC TIER 01FLUORIDE CHW 0.5MG F GENERIC TIER 01FLUORIDE CHW 1MG F GENERIC TIER 01FLUORIDEX GEL 1.1% GENERIC TIER 01FLUORIDEX GEL WHITENIN GENERIC TIER 01FLUORITAB CHW 0.25MG F GENERIC TIER 01FLUORITAB CHW 0.5MG F GENERIC TIER 01FLUORITAB CHW 1MG F GENERIC TIER 01FLUORITAB CHW 2.2MG GENERIC TIER 01FLUORITAB DRO 0.125MG GENERIC TIER 01FLURA‐DROPS DRO 0.125MG GENERIC TIER 01FLURA‐DROPS DRO 0.25MG F GENERIC TIER 01GEL‐KAM CON 0.63% Brand‐O TIER 03 PAKARIDIUM DRO 0.125MG GENERIC TIER 01KARIGEL GEL 0.5% GENERIC TIER 01KARIGEL‐N GEL 1.1% GENERIC TIER 01LOZI‐FLUR LOZ 1MG F GENERIC TIER 01LUDENT CHW 0.25MG F GENERIC TIER 01LUDENT CHW 0.5MG F GENERIC TIER 01LUDENT CHW 1MG F GENERIC TIER 01LURIDE CHW 0.25MG F Brand‐O TIER 02 PALURIDE CHW 0.5MG F Brand‐O TIER 02 PALURIDE CHW 1MG F Brand‐O TIER 03 PALURIDE DRO 0.5MG/ML Brand‐O TIER 02 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= DrugExclusion85