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 NAFRINSE CHW 1MG F GENERIC TIER 01NAFRINSE DRO 0.125MG GENERIC TIER 01NAFRINSE DLY SOL /NEUTRAL BRAND TIER 03NAFRINSE WK SOL 0.2% BRAND TIER 03NEUTRAGARD GEL 1.1% GENERIC TIER 01PERIO MED CON 0.63% GENERIC TIER 01PHOS‐FLUR GEL 1.1% GENERIC TIER 01PREVIDENT CRE 5000 PLS Brand‐O TIER 03 PAPREVIDENT GEL 1.1% BER Brand‐O TIER 03 PAPREVIDENT GEL 1.1% CHR Brand‐O TIER 03 PAPREVIDENT GEL 1.1% MIN Brand‐O TIER 03 PAPREVIDENT PST 1.1% Brand‐O TIER 03 PAPREVIDENT PST 5000 BST Brand‐O TIER 03 PAPREVIDENT SOL RINSE Brand‐O TIER 03 PASF GEL 1.1% GENERIC TIER 01SF 5000 PLUS CRE 1.1% GENERIC TIER 01SOD FLUORIDE CHW 0.25MG F GENERIC TIER 01SOD FLUORIDE CHW 0.5MG F GENERIC TIER 01SOD FLUORIDE CHW 1.1MG GENERIC TIER 01SOD FLUORIDE CHW 1MG F GENERIC TIER 01SOD FLUORIDE CHW 2.2MG GENERIC TIER 01SOD FLUORIDE DRO 0.5MG/ML GENERIC TIER 01SOD FLUORIDE SOL 0.2%MINT GENERIC TIER 01SOD FLUORIDE TAB 0.5MG F GENERIC TIER 01SOD FLUORIDE TAB 1MG F GENERIC TIER 01STAN FLUORID CON 0.63% GENERIC TIER 01THERA‐FLUR‐N DRO 1.1% Brand‐O TIER 03 PACATECHOL‐O‐METHYLTRANSFERASE(COMT)INHIB. COMTAN TAB 200MG BRAND TIER 03ENTACAPONE TAB 200MG GENERIC TIER 01TASMAR TAB 100MG BRAND TIER 03CATHARTICS AND LAXATIVES BASE C PEG LIQ 300 GENERIC TIER 99 DECASCARA EXT SAGRADA GENERIC TIER 01CASCARA SAGR EXT GENERIC TIER 01CASCARA SAGR EXT AROMATIC GENERIC TIER 01COLYTE/FLAVR SOL PACKS BRAND TIER 02 PACOLYTE/FLAVR SOL PACKS Brand‐O TIER 03 PAGAVILYTE‐C SOL GENERIC TIER 01 PAGAVILYTE‐G SOL 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= DrugExclusion86